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Nutrition Screening and Level of Care Assessment for Patients with Eating Disorders – Adult/Pediatric – Ambulatory

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1
Nutrition Screening and Level of Care
Assessment for Patients with Eating
Disorders – Adult/Pediatric – Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 5
METHODOLOGY ...................................................................................................................... 6
DEFINITIONS ............................................................................................................................ 6
INTRODUCTION ....................................................................................................................... 7
RECOMMENDATIONS .............................................................................................................. 8
Screening and Assessment ..................................................................................... 8
Determining Level of Care ....................................................................................... 8
Patients Eligible for Management in Ambulatory Setting ....................................... 11
Patients Ineligible for Management in Ambulatory Setting .................................... 11
Special Considerations.......................................................................................... 11
UW HEALTH IMPLEMENTATION ............................................................................................13
REFERENCES .........................................................................................................................14
APPENDIX A. GRADING SCHEMES .......................................................................................15
APPENDIX B. ...........................................................................................................................16
APPENDIX C. ...........................................................................................................................17
Note: Active Table of Contents -- Click to follow link
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2
CPG Contact for Content:
Name: Cassie Vanderwall, MS, RD, CD, CDE, CPT – Clinical Nutrition
Email Address: CVanderwall@uwhealth.org
CPG Contact for Changes:
Name: Lindsey Spencer, MS – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Guideline Author(s):
Karen Kritsch, Sarah Schumacher, Sarah Van Riet, Cassie Vanderwall
Coordinating Team Members:
Karen Block, BS – Health Education Manager
Sarah Schumacher, MS, RDN, CD, CDE – Health Education
Sarah Van Riet, RDN, CD, CDE – Health Education, UWHC Teen Clinic
Rachel Parks, MS, RDN, CD, CNSC – Clinical Nutrition
Diane Olson, MS, RDN, CD, CDE – Clinical Nutrition
Karen Kritsch, PhD, RDN, CD – Clinical Nutrition Manager
Janice Singles, PsyD – Distinguished Psychologist, Health Psychology
Paula Cody, MD - UWSMPH, UWHC Teen Clinic
William Taft, MD – Psychiatry
Kathleen Carr, MD – Family Medicine
Sarina Schrager, MD – Family Medicine
Ann Evensen, MD – Family Medicine
Melissa Mashni, MD – Family Medicine
Review Individuals/Bodies:
Megan Waltz, MS, RDN, CD, CNSC – Culinary and Clinical Nutrition Services Director
Committee Approvals/Dates:
Nutrition Committee
Clinical Knowledge Management (CKM) Council
Release Date: 12/2014
Next Review Date:
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3
Executive Summary
Guideline Overview
The 2006 American Psychiatric Association (APA) Guideline1 served as the primary
outline for this document. This guideline provides indications and recommendations for
care management by a qualified UW Health Registered Dietitian Nutritionist (RDN) in
the ambulatory setting for patients diagnosed with an eating disorder.
Key Practice Recommendations
The present Clinical Practice Guidelines (CPG) provides recommendations to
standardize the screening and scheduling of patients with an eating disorder. The key
recommendations include:
1. The training of all UW Health nutrition scheduling staff and qualified RDNs on the
present CPG.
2. A qualified UW Health RDN completes the Ambulatory Eating Disorder Screening
Assessment with all prospective patients with an eating disorder to determine the
appropriate level of care.
3. All patients with an eating disorder who are scheduled with a UW Health RDN must:
ξ Have a referring provider who places the consult for nutrition services and agrees
to manage the patient’s medical needs in the ambulatory setting.
ξ Have concurrent appointments with a licensed therapist, psychologist, or social
worker, or be in the process of establishing care (e.g. the patient has an
upcoming appointment with a mental healthcare provider).
4. In order to continue to receive care in the ambulatory setting, all patients with an
eating disorder must:
ξ Agree to regular weight checks as determined by the RDN.
ξ Agree to continue appointments with mental healthcare provider(s).
ξ Demonstrate progress toward goals mutually set by the RDN, patient, and other
members of the patient’s healthcare team.
Companion Documents
1. Nutrition Scheduling Algorithm
2. UW Health Eating Disorders – Adult/Pediatric – Inpatient Clinical Practice Guideline
Pertinent UW Health Policies & Procedures
1. UWMF Policy – MF Person at Risk for Suicide
2. UWHC Policy 10.10 – Suicide Assessment and Prevention
3. UWHC Policy 8.14 – Suicide Assessment and Intervention in Clinic
4. UWHC Policy 10.22 – Admission & Discharge of Patients To & From the Inpatient
Psychiatric Unit
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Patient Resources
1. HFFY #168 – Healthy Eating/Wellness: Your Eating Plan
2. HFFY #264 – Healthy Eating/Wellness: Balanced Food Plan (Rule of Threes)
External Resources:
For the Healthcare Professional-
1. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating.
Disorders. J Am Diet Assoc. 2011;111:1236-1241.
2. Practice Paper of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating
Disorders.
3. American Dietetic Association. Standards of practice and standards of professional performance for
registered dietitians in disordered eating and eating disorders. J Am Diet Assoc. 2011;111:1242-
1249.
4. Academy of Eating Disorders. http://aedweb.org/web/index.php
5. Mehler, P & Andersen A. Eating Disorders: A Guide to Medical Care and Complications. Second
edition. John Hopkins Press, 2010.
6. Herrin M & Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. Routledge Press,
2012.
7. Reiff, Dan and Kathleen Kim Lampson Reiff. Eating Disorders: Nutrition Therapy in the Recovery
Process. Aspen Publishing, 1997.
8. American Dietetic Association and SCAN DPG. Pocket Guide to Eating Disorders.
For the Patient-
1. National Institutes of Mental Health. http://www.nimh.nih.gov/health/publications/eating-
disorders/index.shtml
2. Eating Disorder Foundation.
3. http://www.eatingdisorderfoundation.org/GettingHelpforPatient.htm
4. Eating Disorder Resource Center. http://www.edrcsv.org/
5. National Eating Disorders Association (NEDA). http://www.nationaleatingdisorders.org/index-
handouts
6. National Alliance of Mental disorders.
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Eatin
g_Disorders.htm
7. ECRI Institute. Bulimia Nervosa Resource Guide. www.Bulimiaguide.org
8. Family-based Treatment of Adolescent Anorexia Nervosa: The Maudsley Approach.
http://www.maudsleyparents.org/
9. Brown H. Brave Girl Eating: A family’s struggle with Anorexia. HarperCollins Publishers, 2010.
10. Schaefer J & Rutledge T. Life Without Ed: How one woman declared independence. McGraw-Hill
Education, 2004, 2014.
11. Herrin M & Matsumoto N. The Parent's Guide to Eating Disorders: Supporting Self-Esteem, Healthy
Eating, and Positive Body Image at Home. 2nd Edition. Gurze Books, 2007.
12. Sacker IM & Zimmer MA. Dying to Be Thin. Warner Books, Inc. 1987.
13. Mendelsohn S. It’s Not About the Weight; Attacking eating disorders from the inside out. iUniverse
Books, 2007.
14. Berg F. Afraid to Eat: Children and Teens in Weight Crisis. 3rd Edition. Healthy Weight Network, 2001.
15. Walsh T & Cameron VL. If Your Adolescent Has an Eating Disorder: An Essential Resource for
Parents (Adolescent Mental Health Initiative). Oxford University Press, Inc. 2005.
16. Cash T. The Body Image Workbook: An Eight-step Program for Learning to like your Looks. New
Harbinger Publications, 1997.
17. Cohn L & Hall L. Bulimia, A Guide to Recovery. Gurze Books, 2011.
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Scope
Disease/Condition(s):
Eating Disorders, which include but are not limited to:
ξ Anorexia Nervosa,
ξ Avoidant/Restrictive Food Intake D/O,
ξ Bulimia Nervosa, and
ξ Binge Eating Disorder.4
Clinical Specialty: Clinical Nutrition Services, Health Education
Intended Users:
Registered Dietitian Nutritionists (RDN) (also known as Registered Dietitian, RD) and
Clinical Nutritionists (MS, RDN) within UWHC Department of Clinical Nutrition Services
and UWMF Department of Health Education), Nutrition Schedulers, Internal Medicine,
Family Medicine, Health Psychology, and Psychiatry
CPG objective(s):
To provide evidence-based recommendations that guide RDN practice in determining
which patients diagnosed with an eating disorder may be appropriately managed and
cared for in the UW Health ambulatory setting.
Target Population:
ξ Any adult or pediatric patient (2 to 18 years) diagnosed with an eating disorder
requiring medical nutrition therapy (MNT) at UW Health ambulatory clinics.
ξ Any non-UW Health adult or pediatric (2 to 18 years) patient diagnosed with an
eating disorder requiring MNT who does not have access to an RDN trained in
MNT for eating disorders in their medical home.
Major Outcomes Considered:
The primary outcome for the Scheduling and Assessment of Patients with Eating
Disorders CPG is to establish a screening procedure that:
ξ Ensures that patients with eating disorders seen in nutrition ambulatory clinics
are appropriate for that level of care (level 1) and
ξ Directs patients with an eating disorder that requires a higher level of care on to
more intensive programs (inpatient, residential) in interest of patient safety and
optimal patient care.
Secondary outcomes for the present CPG include:
ξ Rate of weight gain1,6,7
ξ Return of menses for female patients1
ξ Reduction in the frequency or severity of eating disorder behaviors1
ξ Weight stability7, 8
ξ Improved dietary composition8,9
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Guideline Metrics:
1. Proportion of patients managed within the correct setting1,10:
a. Level 1 – Ambulatory
b. Level 2 – Partial Hospitalization or Day Program
c. Level 3 – Inpatient or Residential
Methodology
Methods Used to Collect/Select the Evidence: The workgroup reviewed
previously published external guidelines, and conducted electronic searches using
PubMed and other databases.
Methods Used to Formulate the Recommendations: The workgroup
adopted recommendations developed by external organizations and/or arrived at a
consensus through discussion of the literature evidence and expert experiences.
Methods Used to Assess the Quality and Strength of the Evidence/
Recommendations: The workgroup used two rating schemes based upon the
sources of each recommendation. The modified Grading of Recommendations,
Assessment, Development and Evaluation (GRADE) rating scheme developed by the
American Heart Association (AHA) and American College of Cardiology (ACC) was
used to assess the quality and strength of the evidence and recommendations not
indicated by the American Psychiatric Association (APA).1
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for each grading scheme.
Definitions
The following definitions are verbatim from the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders, fourth and fifth editions (DSM-IV
and DSM-V):
Anorexia Nervosa is defined as2-4:
ξ A refusal to maintain body weight at or above a minimally normal weight for age
and height (e.g. weight loss leading to a maintenance of body weight less than
85% of that expected, or failure to make expected weight gain during period of
growth, leading to body weight less than 85% of that expected).
ξ Intense fear of gaining weight or becoming fat, even though underweight.
ξ Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
ξ In post-menarcheal females, amenorrhea, i.e. the absence of at least three or
more consecutive menstrual cycles. (A woman is considered to have
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7
amenorrhea if her periods occur only following hormone, e.g. estrogen,
administration).
Bulimia Nervosa is defined as2-4:
ξ Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
1. Eating an amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that
one cannot stop eating or control what or how much one is eating).
ξ Recurrent inappropriate compensatory behavior in order to prevent weight gain,
such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other
medications; fasting; or excessive exercise.
ξ The binge eating and inappropriate compensatory behaviors both occur, on
average, at least twice a week for 3 months.
ξ Self-evaluation is unduly influenced by body shape and weight.
ξ The disturbance does not occur exclusively during episodes of Anorexia
Nervosa.
Binge eating disorder is defined as recurring episodes of eating significantly more
food in a short period of time than most people would eat under similar circumstances,
with episodes marked by feelings of lack of control. Someone with binge eating disorder
may eat too quickly, even when he or she is not hungry. The person may have feelings
of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This
disorder is associated with marked distress and occurs, on average, at least once a
week over three months.3
Introduction
Eating disorders are complex illnesses that affect both pediatric and adult populations
with increasing frequency. Pediatric and adult patients have unique features related to
developmental processes, environmental and family stressors, life experiences and
comorbid conditions that are critical considerations in determining the diagnosis,
treatment, and outcome of eating disorders. Patients experiencing serious medical
compromise often require hospitalization.1,5 The present CPG is focused on providing
recommendations for choosing the appropriate treatment setting for patients with an
eating disorder.
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Recommendations
Screening and Assessment
Patients with an eating disorder may be treated across inpatient, outpatient, or
residential settings and it is important to determine the appropriate setting in order to
maximize the benefits of treatment. Pretreatment evaluation of patients with an eating
disorder diagnosis is essential in choosing the appropriate treatment setting.1,5 (APA
Grade I)
Any patient who meets the following criteria should complete the Ambulatory Eating
Disorder Screening Assessment (See Appendix B): (UW Health Class IIa, LOE C)
ξ Have a referral and coexisting medical care from their primary care provider.
ξ Have concurrent appointments with a licensed therapist, psychologist, or social
worker, or being the process of establishing care (e.g. the patient has an upcoming
appointment with a mental healthcare provider.)
ξ Agree to regular weight checks as determined by the RDN
ξ Demonstrate progress toward goals mutually set by the RDN, patient, and other
members of the patient’s healthcare team.
UW Health Ambulatory Eating Disorder Screening Assessment
1. Is the patient under the care of a UW-Health physician or does the patient have a
UW-Health Primary Care Provider (PCP)?
2. Is the patient actively working with a mental healthcare provider or have visits
scheduled with a mental healthcare provider?
3. Does the patient meet the weight guideline appropriate for Level 1 care?
The patient’s referring provider, or PCP, should agree to manage the patient’s medical
needs in the ambulatory setting. Therefore, patients whom answer “yes” to all three
questions of the Screening Assessment may be eligible for management within the
ambulatory setting.
Determining Level of Care
It is important to consider the patient’s overall physical condition, psychological status,
degree and control over eating disorder behaviors, level of functioning, and social
circumstances rather than relying on one or more physical parameters (such as weight)
when determining a patient’s initial level of care.1,5 (APA Grade I)
Currently, the literature defines three levels of care for the treatment of an eating
disorder.1,10
ξ Level 1 – Ambulatory
o Treatment and management of patients within the primary care setting via
a multidisciplinary team, which may or may not be housed in the same
location. Treatment includes regular visits with all team members, which
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may include a primary care physician, registered dietitian nutritionist,
nurse, social worker, and licensed therapist.
ξ Level 2 – Partial Hospitalization or Day Program
o An intermediate level of care for patients who require more than
ambulatory care but less than 24-hour hospitalization. These programs
prevent the need for hospitalization and function as a “step- down” from
inpatient to ambulatory care.
ξ Level 3 – Inpatient or Residential
o The greatest level of care that provides 24-hour surveillance and
treatment with a multidisciplinary team. Hospital-based treatment is less
common with suitable level 1 and 2 treatment programs.
The ambulatory RDN should confirm that the patient is at Level 1 for all required level of
care variables as described by the APA1,5:
ξ Medical status;
ξ Suicidality;
ξ Weight, as the percentage of healthy body weight;
ξ Motivation to recover;
ξ Co-occurring physical and mental disorders;
ξ Structure needed for eating/gaining weight;
ξ Ability to control compulsive behaviors, including exercising, purging, and
binging;
ξ Psychosocial and environmental problems; and
ξ Geographic availability of treatment program.
It is important to note that there are three exceptions to the aforementioned definition.
ξ If the prospective patient is 80-85% of his or her ideal body weight (IBW) and all
other variables are within Level 1 criteria, the RDN, may offer the patient up to
three ambulatory visits over a 6-week period to establish healthy eating habits
and weight gain to reach >85% IBW. (UW Health Class IIa, LOE C)
ξ If the prospective patient is > 80-85% IBW and two or more other variables are at
Level 2 or greater, the RDN may use his or her clinical judgment to either
continue visits, or may decline care in the ambulatory setting and work with the
patient primary care provider to refer the patient to other programs and resources
for more intensive eating disorder treatment. (UW Health Class IIa, LOE C)
ξ In the pediatric adolescent population, the RDN may consult with patients beyond
Level 1 (Table 1) provided the oversight of a medical provider in the eating
disorder specialty, and both parties concur on expert opinion.
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Table 1. Key characteristics of patients with eating disorders, by level of care1,10
Variable Level 1: Outpatient Level 2: Partial Hospitalization Level 3: Inpatient or Residential
Medical status Stable. Extensive medical monitoring not required
Stable. IV, NG tube, daily
labs not needed
Heart rate is less than 50 bpm during the daytime and less
than 40 bpm when asleep, Health at risk due to medical
status, including but not limited to orthostatic changes, EKG
abnormalities or altered lab values
Weight a
Adult Patient b:
≥ 85% IBW a
Adult patient b:
80-85% IBW a
Adult patient b:
<80% IBW a
Pediatric Patient c:
Greater than the 3rd percentile
for BMI-for-age and/or following
established personal growth
curve
Pediatric Patient c:
ξ Less than the 3rd percentile for BMI-for-age,
ξ Dropped 2 curves from previously established BMI-for-Age curve, or
ξ Delayed or stopped growth after previously established growth curve.
Motivation d
Fair to good motivation to
recover.
Actively participates in sessions
and makes effort to follow
nutrition plan.
Decreased or partial
motivation to recover,
cooperative
Refusal. Eating <1000 kcal/day for extended time. Requiring
enteral nutrition.
Comorbid disorders d,e All comorbid disorders are stable and not disrupting daily life. Presence of comorbid disorders may influence choice of level of care
Structure required for
weight maintenance
Self-sufficient. Follows meal plan
with rare engagement of eating
disorder behaviors.
Needs some structure to
gain weight.
Needs close supervision to ensure calorie intake and guard
against ED behaviors (purge, laxatives, etc.), may be
uncooperative
Purging Behavior Rare or can greatly reduce
incidents in unstructured setting.
Needs help to inhibit
purging or struggles to
stop.
Needs supervision during and after all meals.
Ability to control
exercise
Includes < 30-60 minutes of
exercise per day.
Openly discusses and sets goals
with RD.
Some degree of outside structure beyond self-control is needed to prevent compulsive
exercise.
Social Support d Social support needs met. Decreased social
support.
Limited support from others Severe family or social
problems.
a. Ideal body weight (IBW) is calculated using: Hamwi Formula for Men (106 lbs for first 5 feet + 6 lbs for each inch over 5 feet) and Hamwi Formula for Women
(100 lbs for first 5 feet + 5 lbs for each inch over 5 feet).
b. Adult patients are defined as patients who are greater than 18 years of age.
c. Pediatric patients are defined as patients 2 to 18 years of age.
d. See Appendix C for definitions of psychological terms, including motivation and social support.
e. Common co-morbid disorders include depression, anxiety and substance abuse.1,5
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Patients Eligible for Management in Ambulatory Setting
Pediatric patients who are greater than the 3rd percentile for BMI-for-age and/or
following his or her established personal growth curve and/or adult patients who are
greater than or equal to 85% of his or her ideal body weight and highly motivated to
adhere to treatment, have cooperative families, and have a brief symptom duration may
benefit from treatment in the outpatient setting, but only if they are carefully monitored
and understand that a more restrictive setting may be necessary if persistent progress
is not evident in a few weeks.1 (APA Grade II)
Patients assessed to be at Level of Care 1 are eligible for outpatient management. If the
patient is deemed appropriate for MNT in the ambulatory setting, the RDN will inform
the patient of the need for concurrent therapist appointments, coexisting medical care
from a physician and the minimum weight guideline necessary prior to being seen in the
ambulatory setting. The RDN will also confirm the patient’s appointment and proceed
with appropriate treatment.
Patients Ineligible for Management in Ambulatory Setting
Factors which suggest that hospitalization may be appropriate include rapid or
persistent decline in oral intake, decline in weight despite maximally intensive outpatient
interventions, the presence of additional stressors that interfere with the patient’s ability
to eat, knowledge of weight at which instability previously occurred, co-occurring
psychiatric problems, large degree of denial or resistance to participate in less intensive
settings, and signs and symptoms of medical instability.1 (APA Grade I)
Patients assessed to be at Level of Care 2 or 3 are inappropriate for treatment
management in the ambulatory setting. If the patient is deemed inappropriate, the
ambulatory RDN will inform the patient of the intensive care options and encourage the
patient to contact their health insurer to determine coverage for that service.
Local external resources for Levels of Care 2 and 3 include:
ξ Roger’s Memorial Hospital (Oconomowoc, WI)
Rogers Memorial Hospital has an effective phone screening process to evaluate
eating disorder severity and provide guidance for the appropriate level of care for
inpatient and admissions. The RDN can refer the patient to this resource’s free
screening by encouraging them to call (800) 767-4411 or request a screening
online at www.RogersHospital.org.
Additional treatment program and support group options can be viewed at the National
Eating Disorder Association’s website.
Special Considerations
All ambulatory RDN’s will be instructed on pertinent UW Health policies and procedures
related to suicidal ideation and implied risk of suicidal behavior, including:
ξ UWMF Policy – MF Person at Risk for Suicide
ξ UWHC Policy 10.10 – Suicide Assessment and Prevention
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ξ UWHC Policy 8.14 – Suicide Assessment and Intervention in Clinic
ξ UWHC Policy 10.22 – Admission & Discharge of Patients To & From the
Inpatient Psychiatric Unit
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UW Health Implementation
Potential Benefits:
Standardization of the care setting for patients diagnosed with an eating disorder.
Potential Harms: NA
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for clinical practice
guidelines.
2. Release of the guideline will be advertised in the:
a. Clinical Knowledge Management Corner within the Best Practice
newsletter.
b. Department of Culinary and Clinical Nutrition Services weekly newsletter
3. Notice will communicated via the following departments’ listservs:
a. Department of Family Medicine
b. Department of General Pediatrics and Adolescent Medicine
c. Department of Culinary and Clinical Nutrition Services
4. Links to this guideline will be updated and/or added to specific problems in a
patient’s problem lists within their electronic medical record in Health Link or
equivalent tools. Specific problems associated with eating disorder diagnoses
include:
ξ 307.1: Anorexia nervosa
ξ 307.51: Bulimia Nervosa
ξ 307.50: Eating disorder, unspecified
ξ 307.50: Disordered eating
ξ 307.59: Avoidant/restrictive Food intake disorder
ξ 783.0: Anorexia
ξ 783.21: Intentional or unintentional weight loss situations
ξ 783.22: Underweight
ξ 783.3: Feeding disturbance
ξ 783.6: Polyphagia or Severe binge eating disorder
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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References
1. American Psychiatric Association. Practice guideline for the treatment of patients
with eating disorders, 3rd edition. Am J Psychiatry 163(suppl):1–54, 2006.
2. American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
4. Gerrig RJ & Zimbardo PG. Glossary of Psychological Terms. Psychology And Life,
16/e. Published by Allyn and Bacon, Boston, MA. Copyright 2002 by Pearson
Education. Accessed September 2014.
http://www.apa.org/research/action/glossary.aspx
5. La Via M, Kaye WH, Andersen A, Bowers W, Brandt HA, Brewerton TD, Costin C,
Hill L, Lilenfeld L, McGilley B, Powers PS, Pryor T, Yager J, Zucker ML: Anorexia
nervosa: criteria for levels of care. Paper presented at the annual meeting of the
Eating Disorders Research Society, Cambridge, Mass, November 5–7, 1998.
6. Lund BC, Hernandez ER, Yates WR, Mitchell JR, McKee PA, Johnson CL. Rate of
inpatient weight restoration predicts outcome in anorexia nervosa. Int J Eat Disord.
2009;42:301-305.
7. American Dietetic Association. Position of the American Dietetic Association:
Nutrition Intervention in the Treatment of Eating Disorders. J Am Diet Assoc.
2011;111:1236-1241.
8. American Dietetic Association. Practice Paper of the American Dietetic Association:
Nutrition Intervention in the Treatment of Eating Disorders. J Am Diet Assoc., 2011
9. Le Grange D, Doyle P, Crosby RD, Chen E. Early response to treatment in
adolescent bulimia nervosa. Int J Eat Disord., 2008;41:755-757.
10. Rosen DS & the Committee on Adolescence. Identification and Management of
Eating Disorders in Children and Adolescents. Pediatrics 2010;126;1240.
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Appendix A. Grading Schemes
Figure 1. APA Grading Scheme
I Recommend with substantial clinical confidence.
II Recommend with moderate clinical confidence.
III May be recommended on the basis of individual circumstances.
Figure 2. GRADE Grading Scheme (Modified by AHA/ACC)
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Appendix B.
Nutrition Scheduling Algorithm for Patients with an Eating Disorder
Prospective
Patients Calls
Clinic
Nutrition Scheduler verifies:
1.Referral and coexisting medical care from primary care provider.
2. Concurrent appointments with a licenses therapist, psychologist,
or social worker, or is beginning the process of establishing care
(i.e., upcoming appointment)
3. Patient agrees to regular weight checks.
4. Patient demonstrates progress towards goals mutually set by the
RD, patient, and other healthcare staff
Nutrition Scheduler
holds 3 appointments
which will be confirmed
following screening
assessment
Nutrition Scheduler
sends in-basket
message to prospective
RDN re: Ambulatory
Eating Disorder
Screening Assessment
RDN completes
Ambulatory Eating
Disorder Screening
Assessment
Prospective
Patient
Appropriate?*
* Patients who score XXX and are at Level 1
RDN informs Patient of
requirements for medical
nutrition therapy
No
RDN confirms
appointments with
Patient
Yes
Last revised: 12/2014
Eating Disorders – Adult/Pediatric- Ambulatory
Clinical Practice Guideline
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2014CCKM@uwhealth.org

17
Appendix C.
Glossary of Psychological Terms
Anorexia Nervosa: An eating disorder in which an individual weighs less than 85
percent of her or his expected weight but still controls eating because of a self-
perception of obesity.
Bulimia Nervosa: An eating disorder characterized by binge eating followed by
measures to purge the body of the excess calories.
Comorbidity: The experience of more than one disorder at the same time.
Motivation: The process of starting, directing, and maintaining physical and
psychological activities; includes mechanisms involved in preferences for one activity
over another and the vigor and persistence of responses.
Social Support: Resources, including material aid, socio-emotional support, and
informational aid, provided by others to help a person cope with stress.
Key terms as defined by Gerrig & Zimbardo (2002).5
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2014CCKM@uwhealth.org