developmental and psychiatric disorders ddpd) a dietetic ... · apply to your ada portfolio plan....

AA ppuubblliiccaattiioonn ooff Behavioral Health Nutrition (BHN) (Formerly known as Dietetics in

Developmental and Psychiatric Disorders DDPD) A dietetic practice group of the American Dietetic Association

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T h e R e s o u r c e f o r B e h a v i o r a l H e a l t h N u t r i t i o n

PPssyycchhoottrrooppiicc DDrruugg//FFoooodd IInntteerraaccttiioonnss::WWhhaatt RRDDss NNeeeedd ttoo KKnnoowwBy Dean Elbe, B.Sc. (Pharm.), BCPP

Due to the significant increasein usage of Second-GenerationAntipsychotics over the past sever-al years, most dietitians are wellaware of the nutritional concernssurrounding these medications.However, food-medication interac-tions that can occur with otherclasses of psychiatric drugs may beless familiar, depending on yourcurrent practice setting and patientpopulation.

The class of drugs known asbenzodiazepines is used therapeuti-cally for the treatment of insomniaand anxiety. These drugs also havemuscle relaxant and anticonvulsantproperties. Diazepam (Valium) isone of the oldest and best knowndrugs in this class. Other common-ly used benzodiazepines includelorazepam (Ativan®), clonazepam(Klonopin®), alprazolam(Xanax®), oxazepam (Serax®),temazepam (Restoril®), triazolam(Halcion®) and midazolam(Versed®). Sedation, drowsiness,ataxia, fatigue, dizziness and othercentral nervous system effectsoccur with these drugs and the riskfor these effects increases withconcurrent alcohol intake.1

Benzodiazepines are stored in fattytissues, and can accumulate therein obese individuals. When a ben-zodiazepine is used for surgicalanesthesia, the loading dose needsto be based on actual weight, andmaintenance doses should beadjusted based on ideal body

weight.2 All drugs in this classhave the potential to cause physicaland psychological dependence.Patients who take these medica-tions in large doses or for longperiods of time may require grad-ual, scheduled dose reduction (alsocalled “tapering”) in order to safe-ly discontinue their use.

Some, but not all benzodi-azepines interact significantlywhen taken with grapefruit juice.Blood levels and total drug expo-sure increase with diazepam(Valium), triazolam (Halcion) andmidazolam (Versed). It should benoted that grapefruit-drug interac-tions only occur with medicationsadministered orally. When benzo-diazepines or other drugs are givenby injection, they are not subject tointeraction with grapefruit.

Medications prescribed forAttention-Deficit/HyperactivityDisorder (ADHD) generally fallinto one of three categories: 1.)stimulant medications includingamphetamine-type drugs, 2.)methylphenidate which is availablein several different dosage forms,and 3.) agents with mechanismsof action similar to antidepressants(dopamine and/or norepinephrinereuptake inhibitors), such as atom-oxetine (Strattera). Stimulantsappear to affect central dopaminelevels by blocking reuptake ofdopamine and possibly by increas-ing dopamine release. Similareffects on norepinephrine may con-

tribute to the therapeutic effects ofstimulants as well.

Stimulant medications are con-troversial, both due to the frequen-cy with which they are prescribed,as well as the potential to affectgrowth with long-term usage. Arecent meta-analysis3 of stimulantuse in children with ADHDshowed a pattern of initial weightloss which was followed by even-tual resumption of weight gain,and a slowing of the change inheight by approximately 1 cm/yearduring the first three years of treat-ment. A meta-analysis4 of the non-stimulant medication atomoxetine(Strattera) also showed significanteffects on growth early in treat-ment, followed by a reduction ofeffects after two years of treatment.

What about the nutritionaleffects of the Second-GenerationAntipsychotics? Are certain psy-chiatric medications more likely tocause weight gain, lipid disordersor lead to new-onset diabetes? Tolearn answers to these questionsand more, I would like to inviteyou to attend the seminar I am pre-senting with your colleague,Zaneta Pronsky, RD, MS, FADA.We will be the Behavioral HealthNutrition (BHN) Priority Sessionspeakers at the upcomingAmerican Dietetic AssociationFood & Nutrition Conference &Expo in Philadelphia. Mark yourcalendars for Tuesday October 2ndfrom Noon to 1:30 p.m. (Session#

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Fellow members, this is indeedan exciting time for all of us. It ismy delight to be able to talk withyou about our DPG name changeand about meeting you at theAmerican Dietetic Association’s(ADA) Food & NutritionConference & Expo (FNCE) 2007,

Philadelphia, PA. First, let me tell you about our name change. On

August 13th our Executive Committee received confir-mation from our Practice Team Manager, FrancesAustin, RD, that our proposal for changing our namefrom Dietetics in Developmental and PsychiatricDisorders (DDPD) to Behavioral Health Nutrition(BHN) had been approved by the ADA Board ofDirectors. We are now officially Behavioral HealthNutrition (BHN)!

Your participation in our member survey was key inthe decision process. Our BHN Executive Committeewill continue to look to you for decision making. I findthis process rather like redesigning our PracticeGroup’s home office. Kathy Russell, MS, RD(Membership Chair) will be asking for your input onnew colors and design styles for the BHN Web site.Melody Rankin, RD, LD, (our Newsletter Editor) willbe asking you about a new look for our BHN newslet-ter. We are currently evaluating the visual representa-tion of BHN. I hope you will join in the process ofrepainting and redesigning our Behavioral HealthNutrition home office. We want it to be a modern,user-friendly but comfortable place where we can allwork together to promote the nutritional health ofthose we serve.

Second, I get to tell you about the events we haveplanned for you this fall at ADA’s FNCE 2007. Wehave planned something for you every day. We want tomeet you! Please introduce yourself to BHN officers.Our officers are making plans to be available to talkwith you at each of these events:

Saturday, September 29th, noon to 3 p.m. will beour BHN Pre-FNCE workshop, titled “EatingDisorders 9-1-1”. All of us work with or will workwith people who exhibit a disordered pattern of eatingand who do not wish to change. Jessica Setnick, MS,

FFrroomm TThhee CChhaaiirrPaula Kerr, MS, RD, CD

continued on page 10

From the Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2BHN Schedule of Events at Food & Nutrition conference

& Expo 2007 (FNCE) Philadelphia, PA . . . . . . . . . 3ADA’s Regulatory Comments Update . . . . . . . . . . . . . . 4Case Study in Substance Abuse. . . . . . . . . . . . . . . . . 5, 6What’s Eating Your Patients? How to Solve Emotional

Eating from the Inside Out . . . . . . . . . . . . . . . 6, 8-13Gene Linked to Autism in Families with More Than One

Affected Child . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 8Request for Nominations . . . . . . . . . . . . . . . . . . . . . . . 14BHN Executive Contacts . . . . . . . . . . . . . . . . . . . . . . . 15

IINNSSIIDDEE TTHHIISS IISSSSUUEE

DevelopMental Issues is published quarterly (Winter,Spring, Summer, Fall) as a publication of Behavioral HealthNutrition, a dietetic practice group of the American DieteticAssociation.

The views expressed in this publication are those of theauthor and are not necessarily those of the AmericanDietetic Association. Mention of product names in thispublication does not constitute endorsement by BHN orADA.

Advertisements in DevelopMental Issues should not beconstrued as an endorsement of the advertiser or the prod-uct by the American Dietetic Association or the BHN prac-tice group.

Articles about successful programs, research interventions,evaluations and treatment strategies, meeting announcementsand information about educational programs are welcomeand should be sent to the editor by the next deadline.

Future DeadlinesWinter 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . .January 10, 2008Spring 2008 . . . . . . . . . . . . . . . . . . . . . . . . . .February 28, 2008Summer 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . .March 31, 2008Fall 2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .June 30, 2008

Please forward information or article submissions to:Melody Rankin, RD, LD

14373 Glenview Drive • Choctaw, OK 73020Fax: 405-390-1539 • [email protected]

Newsletter Review Board:Paula Kerr, MS, RD, CD

Karen Jircitano, RD, LDNFrances Austin, RD

Subscription cost for individuals not eligible for ADA membership is$25.00. A check or money order should be made payable to ADA/DPG#12 and sent in care of the newsleter editor.

©2007 Copyright by BHN. All rights reserved.

BBHHNN SScchheedduullee ooff eevveennttss aatt FFoooodd && NNuuttrriittiioonnCCoonnffeerreennccee && EExxppoo 22000077 ((FFNNCCEE)) PPhhiillaaddeellpphhiiaa,, PPAA• Saturday 12 p.m. -3 p.m. Eating Disorders 9-1-1 workshop (J. Setnick presenter)• Sunday 6 p.m. BHN Member Social – Marriott Downtown Philadelphia Lobby Lounge• Monday 10:30 a.m.-1:00 p.m. DPG Showcase (Look for us in Booth #18)• Tuesday 12 p.m. -1:30 p.m. BHN DPG Priority Session: Psychotropic Drug/Food Interactions: What

RDs Need to Know• ADA Foundation Silent Auction: BHN has donated a Laptop computer to help raise funds for ADA

Foundation Student Scholarships. Put in your bids…

SSeessssiioonn:: MM661199Eating Disorders 9-1-1A special pre-FNCE Workshop

Conducted by: Jessica Setnick MS RD(Founder of “Eating Disorders Boot Camp”)

WWhheenn:: Saturday, September 29, 2007 12:00 p.m. – 3:00 p.m. WWhheerree:: Courtyard by Marriott, PhiladelphiaRRoooomm:: Juniper RoomCCoommpplleemmeennttaarryy:: Jessica’s text “The Eating Disorders Clinical Pocket Guide”BBuuffffeett LLuunncchh iiss iinncclluuddeeddCCPPEEUU HHoouurrss:: 33..00 LLeevveell 22 SSuuggggeesstteedd LLeeaarrnniinngg NNeeeeddss CCooddeess:: 55220000,, 55332200,, 33000000,, aanndd ootthheerrss tthhaatt mmaayyaappppllyy ttoo yyoouurr AADDAA ppoorrttffoolliioo ppllaann..

LLeeaarrnn::• How to design a meal plan for a patient with an eating disorder.• How to convince your patients “it’s not about food.”• How to make recommendations that your patients will want to follow.

EEaarrllyy bbiirrdd rreeggiissttrraattiioonn:: $65 BHN members before September 20th, 2007 Register online at: www.eatright.org/ddpd-fnce

LLaattee RReeggiissttrraattiioonn:: $75 BHN members After September 20th, 2007 register on-site at FNCE

About the presenter: Jessica Setnick, MS, RD/LD, is an internationally known pediatricdietitian in Dallas, Texas. In addition to training professionals around the country at EatingDisorders Boot Camp, Jessica meets with children and teens in her office or their homes toaddress a variety of weight and eating issues. An award-winning writer, Jessica has been rec-ognized for her tireless efforts at communicating nutrition messages in an understandableway. Now recovered from her own eating disorder, Jessica’s passion is promoting a positiverelationship with food and eating as a key component of a healthy and happy life.

Sponsored by: Behavioral Health Nutrition (BHN) DPG #12

Keeping up todate with TheAmericanDieteticAssociation’s(ADA)RegulatoryComments is

simple with internet access. EachADA member can access the ADAweb site, www.eatright.org, andclick on the Advocacy and theProfession tab to link to theRegulatory Comments Web site.Below is a quick summary of cur-rent ADA Regulatory Commentsthat should be of interest to ourgroup:

Comments on Early InterventionProgram for Infants andToddlers with Disabilities

The Department of Educationpublished proposed rules in theFederal Register for the EarlyIntervention Program for Infantsand Toddlers with Disabilities inMay 2007. However, the proposedrules did not include the definitionof nutrition services as defined inthe current rules. ADA recom-mended that the Department ofEducation retain the current defini-tion of nutrition services of theRegistered Dietitian among theother types of services. Inresponse to an action alert, ADAmembers also sent comments. The

majority of the comments receivedby the Department of Educationsupported the inclusion of the defi-nition of nutrition services.

FDA-proposed Gluten-free LabelClaim

The Food and DrugAdministration (FDA) publishedproposed rules for ‘gluten-free’labeling in January 2007. ADAanswered FDA’s questions regard-ing the rules:

• Oats should not be listed among the prohibited grains.

• A disclaimer should be added if foods inherently ‘gluten-free’ may be exposed to glutenin processing and/or contain food additives that contain a significant amount of gluten.

• A disclaimer should be added to qualify the amount of gluten per gram of food to better inform consumers of the ‘gluten-free’ claim.

• A ‘low-gluten’ claim is not scientifically justified.

Overall, ADA believes that theFDA considered well a range ofoptions available to food producersbased on the best scientific andmethodological data available toestablish a definition for a ‘gluten-free’ claim.

BHN members are asked tosubmit their public policy concernsto the Public Policy Liaison for

collaboration: c/o Andrea Shotton,6718 Durango Dr., Magnolia, TX77354.

Additionally, ADA’s PublicPolicy Workshop (PPW) is sched-uled for February 4-6, 2008 at theRenaissance in Washington, DC.The agenda for the workshop hasnot been announced as yet. Moreinformation will be posted on theADA Web site after Labor Day.PPW is designed to help attendeeslearn more about ADA priorityissues before Congress and to gettraining on grassroots lobbying.

In addition, for those memberswho still need further education onthe Coding and Coverage forMedical Nutrition Therapy (MNT),ADA is offering the following ses-sions at FNCE 2007 inPhiladelphia:

• Optimize Your Claims – How a Billing Service Can Work For You

• Networking session for RDs participating in the RD Coding Network

• MNT Codes and Medicare Resources

For further information on thesesessions access the ADA Web site,www.eatright.org, and click on theAdvocacy and the Profession tabto link to the Medical NutritionTherapy Web site.

AADDAA’’ss RReegguullaattoorryy CCoommmmeennttss UUppddaatteeAndrea Shotten, MS, RD, LDNBHN Public Policy Chair

206). I look forward to seeing youall there.

References:

1. Pronsky ZM. Food-Medication Interactions, 14thEd. Birchrunville, PA: Food-MedicationInteractions, 2005.

2. Casati A, Putzu M. Anesthesia in the obesepatient: Pharmacokinetic considerations. J ClinAnesth 2005; 17: 134-45.

3. Poulton A. Growth on stimulant medication; clari-fying the confusion: a review. Arch Dis Child2005; 90: 801-6.

4. Kratochvil CJ, Wilens TE, Greenhill LL et al.Effects of long-term atomoxetine treatment for

young children with attention-deficit/hyperactivi-ty disorder. J Am Acad Child Adolesc Psychiatry2006;45: 919-27.

WWhhaatt RRDD’’ss NNeeeedd ttoo KKnnoowwcontinued from page 1

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When a nutrition consultation isordered and time is limited, howyou approach the consult maychallenge both your skills and yourknowledge. I have found that themajority of patients completingmedical detoxification are notready to discuss their medical ornutritional problems. What shouldI assess for? Should I initiate nutri-tion counseling? As the patient’sdietitian, I usually have only onechance to determine the patient’snutrition care plan. What makesthis consultation especially chal-lenging is that the patient will bedischarged within 5 days, the time-frame in which medical detoxifica-tion from drugs and/or alcohol isusually completed. I found that tobe the case when I responded tothe doctor’s request for nutritionconsultation with patient, “John”.

Medical Record Review: “John”is a 35 year old man. He is able tospeak, read and write English. Hehas a technical school degreebeyond high school. This is his10th known detoxification fromalcohol and/or drugs. Last visit toAcute Substance Abuse TreatmentUnit (ASATU) was 4 years ago.He is admitted for alcohol abuseand opiate dependence. He hadbeen on Methadone for 4 years,but stopped 8 months ago.Methadone Maintenance Therapy(MMTP) will not resume untilafter discharge. John lives with hiselderly father in his father’s home. Axis III (2):

• Hypertension (HTN)(non-compliant with meds)

• Hepatitis C • History of Diabetes Mellitus

(currently, no medication and a normal FBS as noted on admit labs)

Abdominal surgery for pseudo-cyst on pancreas 3 months prior toadmission. John reportedly stoppedtaking prescribed Pancrease priorto admission due to lack of painrelief. He subsequently increasedthe use of alcohol and cocaine torelieve abdominal pain. Johnreported a “10” for abdominal painon the “Nursing Admission PainAssessment” form.

Admitting Labs: MetabolicProfile is within normal limits,except lab data confirmingHepatitis C.

Anthropometric Data: Height:5’ 9?”. Weight: 162#. BMI: 23.8kg/m2 = Normal Weight. UsualBody Weight of 170 – 180#, with areported history of 40# weight lossrelated to pancreatic cysts andabdominal surgery. (No documen-tation to determine validity of thisinformation. Previous ASATUmedical record and hospital recordnot available.)

Vitals: Blood Pressure (B/P)was elevated at admission andresponded to an antihypertensiveagent. B/P is maintained withinnormal limits with prescribed med-ication as noted on repeat chartreview on day 3 of medical detoxi-fication.

Medications: Norvasc forHTN; Nexium for abdominal dis-tress. Norvasc was started atadmission. Nexium was added onday 3 when MD requested a nutri-tion consultation. Antidiarrhea

agents were ordered at admissionand daily adjustments were madeby medical doctor.

Diet Rx: Regular (DetoxRegular diet of ~2800+ kcals,125+ grams of protein, three mealsand an evening snack).

Other Nutrition RelatedInformation: A nutrition consulta-tion was requested on Day 3. Themedical doctor’s progress notereveals that diarrhea is continuingand not responding appropriatelyto antidiarrhea agents. Progressnote reports continued abdominalpain and suggestion that John mayhave gastroesophageal reflux dis-ease (GERD). John will have afollow-up appointment at the GIClinic of the local hospital thattreated him for pseudocyst to hispancreas 1 week after dischargefrom ASATU.

Medical Nutrition Therapy:John received nutrition therapyservices from this RegisteredDietitian (RD) on Day 4. Johnreported that he had stopped drink-ing milk and eating foods contain-ing milk since age 30 due to lac-tose intolerance. It could not bedetermined if he was drinking milkor eating foods with lactose whilein the Acute Substance Abuse Unit(Detox), as he declined to answermany of the nutrition related ques-tions there. John reported that hisusual meal pattern is two meals aday obtained from fast food estab-lishments. He also reported thathe had been prescribed nutritiontherapy for pancreatitis, but thatthe nutrition consultation did notconcur. John was offered a lactose-controlled, low fat meal plan dur-

CCaassee SSttuuddyy IInn SSuubbssttaannccee AAbbuussee Ellen Tobias, MA, RD

CCaassee SSttuuddyy iinn SSuubbssttaannccee AAbbuusseecontinued from page 5

ing his stay on ASATU. He declinedall nutrition interventions.

Due to multiple medical prob-lems that could respond to nutritiontherapy and the patient’s anticipateddischarge within two days, the RDmust determine the appropriatenutrition therapy interventions thatwill help to relieve or decreaseJohn’s chronic abdominal pain, con-trol his diarrhea, and resolve hissymptoms of GERD while helpinghim to maintain sobriety. The“Lactose Controlled Diet” found inADA Patient Education Materials,Supplement to the Manual ofClinical Dietetics, Third Edition”was utilized, along with the“Sobriety Nutrition TherapySurvival Skills” client educationmaterial from the current “ADAWeb site Nutrition Care Manual.”Nutrition education materials cover-ing dietary modification to controlHTN and symptoms of GERD wereincorporated into John’s instruction.The “Sobriety Nutrition Therapy”handout encouraged nutrition andlifestyle changes that may have apositive impact on blood pressure

control and may help alleviateJohn’s symptoms of GERD. ThisRD usually does not provide twonutrition related handouts, howeverthe lactose nutrition therapy hand-out listed foods that may cause dis-tress, as well as foods allowed. Hisnutrition assessment revealed thatJohn was lacking education on thistopic.

This nutrition therapy interven-tion together with education materi-als that the patient took home withhim can impact John’s physicalhealth, comfort, and his commit-ment to sobriety. John’s situation isnot uncommon. Deciding how tobest help a patient admitted to thehospital for acute detoxificationfrom alcohol or other substancesrequires a thoughtful assessment ofthe patient’s physical health as wellas his or her psychosocial situation.The RD needs to prioritize nutritionissues because of limited time, lim-ited information, and the patient’smotivation to learn and to change.Dietitians who lack education,training and/or experience inBehavioral Health practice may feel

that nutrition counseling on allmedical nutrition issues should beaddressed. Addressing all issuesand utilizing multiple-nutritionhandouts may not be practical.Limiting the number of handoutsand the amount of written informa-tion for patients like John is sug-gested. Offering too much informa-tion can alienate rather than engagethe patient. This RD used twohandouts tailored to John’s immedi-ate medical and nutritional needs.The ADA Nutrition Care Manual*has excellent nutrition informationfor a patient with lactose intoler-ance. A simplified two page hand-out was chosen instead of the threepage version. This helped to engageJohn without overwhelming himand led to a productive counselingsession.

John was discharged to home onDay 5. It is not known if he attend-ed his follow-up medical appoint-ment.

*For information see the ADANutrition Care Manual (NCM), apublication of the American DieteticAssociation (ADA) copyright 2007www.nutritioncaremanual.org

WWhhaatt''ss EEaattiinngg YYoouurr PPaattiieennttss?? HHooww ttoo SSoollvveeEEmmoottiioonnaall EEaattiinngg ffrroomm tthhee IInnssiiddee OOuuttBy Jessica Setnick, MS, RD/LD and Michelle Negri, RD/LDThis article is adapted with permission from Bariatric Times. Subscriptions to Bariatric Times are free to qualified individuals.To subscribe, go to www.bariatrictimes.com and follow instructions for subscription.

The post-surgical patient is sit-ting in your office, tapping herfoot and staring at you. She’s flus-tered and angry because her weightkeeps increasing. She seems to begetting bigger by the moment.Ever since she had surgery, she has

gone through a whole spectrum ofmoods – elated, happy, sad, angry,scared, and now… hysterical. Shewants to know what YOU’re goingto do to make her stop gainingweight!

“Fix me!” she wails, leaning

desperately toward you.

You can’t respond, yourthoughts are a blur…How did I gethere? What will I do? How will Ihelp her? How can I escape?... andthen with a start, you finally wakeup. This time it was only a dream.

continued on page 8

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GGeennee LLiinnkkeedd ttoo AAuuttiissmm iinn FFaammiilliieess wwiitthh MMoorreeTThhaann OOnnee AAffffeecctteedd CChhiillddNIH NewsNational Institutes of HealthNews release Tuesday, October 17, 2006

A version of a gene has beenlinked to autism in families thathave more than one child with thedisorder. Inheriting two copies ofthis version more than doubled achild’s risk of developing an autismspectrum disorder, scientists sup-ported by the National Institutes ofHealth’s (NIH) National Instituteof Mental Health (NIMH) NationalInstitute of Child Health andHuman Development (NICHD)have discovered. In a large sampletotaling 1,231 cases, they tracedthe connection to a tiny variationin the part of the gene that turns iton and off. People with autismspectrum disorders were more like-ly than others to have inherited thisversion, which cuts gene expres-sion by half, likely impairingdevelopment of parts of the brainimplicated in the disorder, reportDrs. Daniel Campbell, Pat Levitt,Vanderbilt Kennedy Center atVanderbilt University, and col-leagues, online during the week ofthe October 16, 2006 in theProceedings of the NationalAcademy of Sciences.

“This common gene variantlikely predisposes for autism incombination with other genes andenvironmental factors,” said Levitt.“It exerts the strongest effectdetected thus far among autismcandidate genes.”

Autism is one of the most heri-table mental disorders. If one iden-tical twin has it, so will the otherin nearly 9 out of 10 cases. If onesibling has the disorder, the othersiblings run a 35-fold greater-than-normal risk of having it. Still, sci-entists have so far had only mixedsuccess in identifying the genesinvolved.

While most previous studieshad focused on genes expressed inthe brain, Levitt’s team saw a cluein the fact that some people withautism also have gastrointestinal,immunological or neurologicalsymptoms in addition to behavioralimpairments. They focused on agene that affects such peripheralfunctions as well as the develop-ment of the cortex and cerebellum,brain areas disturbed in autism.Moreover, it is located in a suspectarea of chromosome 7 that hasbeen previously linked to autismspectrum disorders.

This mesenchymal epithelialtransition factor (MET) receptortyrosine kinase gene codes for aprotein that relays signals that turnon a cell’s internal machinery andis known to play a key role in bothnormal and abnormal development,such as cancer metastases (henceits name). Levitt’s group and othershad earlier found that impairingthe receptor’s signaling interferes

with neuron migration and disruptsneuronal growth in the cortex andsimilarly shrinks the cerebellum —abnormalities also seen in autism.

To explore this possible connec-tion, the researchers looked forassociations between the brain dis-order and nine markers in the METgene, sites where letters in thegenetic code vary among individu-als. They tested two samples: thefirst, 204 families, including 26with more than one child withautism spectrum disorders, the sec-ond, 539 families, including 452with such multiple affected chil-dren.

One marker, the C version,emerged as over-transmitted at“highly significant” levels in peo-ple with autism spectrum disordersin both samples. Moreover, thisassociation held only for familieswith more than one affected childand was strongest in a sub-sampleof those with more narrowly-defined autism. The C version wassignificantly less prevalent in agroup of 189 unrelated controlsthan in the individuals with autismor their parents.

In cell culture tests, theresearchers determined that the Cversion is weak at making theMET receptor protein, resulting ina two-fold reduction in geneexpression compared to the other

GGeennee LLiinnkkeedd ttoo AAuuttiissmmcontinued from page 7

common G version of the gene,with presumably adverse conse-quences on brain development.Inheriting two copies of the C ver-sion boosted risk for autism spec-trum disorders 2.26-fold, whileinheriting one copy of C and oneof G increased risk 1.54-fold.

“Since autism likely involvescomplex interactions betweenmany different genes and otherfactors, common genetic predis-posing factors are likely moreinfluential in families with multi-ple affected members,” explainedLevitt. “Some cases in familieswith only one affected membermore likely stem from rarer geneticglitches or other sporadic events.Hence, finding the link with theMET gene variant only in the for-mer ‘multiplex’ families strength-ens its candidacy.”

The researchers propose that in

some individuals with autism spec-trum disorders who also developdigestive and immune system ornon-specific neurological prob-lems, the MET gene variant mightplay a role in impairing both brainand peripheral organ development.

“We know that autism is themost heritable of neuropsychiatricdisorders, but, thus far, we havenot identified genes that consis-tently are associated with thisdevelopmental brain disease,” saidNIMH Director Thomas Insel,M.D. “This new finding is animportant clue, which if replicatedin an independent sample, will takeus closer to understanding thegenetic basis of autism.”

Also participating in the studywere: Daniel Campbell, JamesSutcliffe, Philip Ebert, VanderbiltUniversity; Roberto Militerni,Carmela Bravaccio, University of

Naples (Italy); Simona Trillo,Associazione Anni Verdi; MaurizioElia, Oasi Maria SS; CindySchneider, Center for AutismResearch and Education; RaunMelmed, Southwest AutismResearch and Resource Center;Roberto Sacco, Antonio Persico,University Campus Bio-Medicoand Fondazione Santa Lucia.

The research was also supportedby The Autism Genetic ResourceExchange (AGRE), Cure AutismNow, the Marino Autism ResearchInstitute, Telethon-Italy, NationalAlliance for Autism Research,Foundation Jerome Lejeune, andNARSAD. For more informationabout autism spectrum disorderssee: http://www.nimh.nih.gov/

healthinformation/autismmenu.

cfm.

But your professional nightmarecould easily happen, if yourpatients have unidentified emotion-al eating.

Emotional eating is a non-tech-nical term that describes eating inresponse to emotions rather thanhunger (1). When emotional eatingbecomes that severe, it is given thename “binge eating disorder” (seechange to Table 1 for symptoms).

For the purposes of this article,emotional eating refers not only toclinically diagnosable patients, butalso to those who don’t meet full

criteria. Emotional eating includespatients who are eating out of pain,whether current or past, and eatingto feel better, numb out, or feelworse. They are eating to helpsolve, prevent, or distract them-selves from problems. They mayhave been traumatized in the past,either because of, or unrelated to,their weight. They may eat in pub-lic to please others, or eat in pri-vate to avoid criticism. Emotionaleating may lead to overweight orobesity, leading an emotional eaterto seek medical help for weight

loss (3,4,5).

When looking into bariatric sur-gery, an emotional eater may beconsciously optimistic, but uncon-sciously terrified. If surgery istheir “last resort,” the additionalstress can actually cause weightgain. The emotional eating may notbe identified during assessment,because the patients themselvesmay not recognize their eatingbehaviors as emotional. They mayclassify their eating as abnormal,but assume that surgery will “fixit.” Most dangerous of all, patients

WWhhaatt’’ss EEaattiinngg YYoouurr PPaattiieennttss??continued from page 6

continued on page 9

may welcome the inability to emo-tionally eat, without realizing thatthey will then be forced into facingcertain emotions that they are usedto relieving with food. For all ofthese reasons, bariatric practition-ers must be increasingly alert todetect emotional eating issues inorder to prevent the devastatingconsequences that otherwise canresult.

If a patient became obese byeating in response to emotionshe/she could not express, surgerymay leave him/her vulnerable tothe same feelings, but with no wayof relieving them (6,4).

Messages in our culture tend tosuggest that weight loss is a cure-all. But any emotional distress thata patient incorrectly attributed toobesity - perhaps loneliness, socialphobia, depression, or shame - willlinger during and after weight lossis achieved. So in addition to theoriginal distressing emotions, apatient may begin to experiencedepression, disappointment, oranger, accompanying the realiza-tion that surgery didn’t “fix” emo-tional issues. (4,7,8).

If a patient finds ways aroundpost-surgery dietary guidelines andreturns to inappropriate or emo-tion-related eating after surgery,he/she may begin to gain weight,which in turn would be expected tocause more negative feelings(7,9,10). Realizing that evenbariatric surgery is not “enough”can be profoundly depressing.Psychiatric centers are anecdotallyreporting increasing numbers of

post-surgery patients with depres-sion, anxiety, and other psychologi-cal distress. Professionals reportthat routinely these patients wereunaware of the beneficial purposeof their emotional eating in bolster-ing their brain chemistry, andtherefore developed no skills tocompensate for its loss. A detailedhistory often reveals one or moreunprocessed traumas, from child-hood abuse and abandonment tomiscarriage, divorce, and familydeaths (9,11,12).

After treating emotional eaterspre-surgery through the Ai PonoEating Disorders Program inHonolulu, Dr. Anita Johnstondescribes these as “frozen” traumaslocked in an iceberg. “Once the icebegins to melt,” she says, “you findall kinds of things buried there.” Inother words, as our patients moveforward after bariatric surgery,their eating behaviors no longerserve to numb them from pastpain. The cracks underneath beginto be revealed, but the patient hasno skills to cope with what theymay find. In many cases, patientsneed surgery, regardless of theiremotional eating status. But theyalso need the additional support ofpsychological care and to knowwhere they will get help beforethere’s a crisis.

Emotional Eating: Why aren’t weidentifying it in pre-surgeryassessments?

First of all, we don’t always ask.You may not feel comfortable ask-ing a patient, “Do you ever eat outof depression or shame?” And it

may not feel comfortable to themto answer. If questions are asked ina written survey format, patientsmay be reluctant to indicate theiremotional eating, not knowing whowill ultimately read their answers.On the other hand, many patientsdon’t identify with the terms“bingeing” or “emotional eating”and therefore don’t equate whatthey’re doing as such. Sometimesit’s a “don’t ask, don’t tell” situa-tion, since patients may fear certainconfessions will prevent or delaytheir surgery. Dr. Johnston pointsout that a lot of our patients don’trecognize the events of their livesas trauma, so it’s impossible forthem to realize the connection withtheir eating.

Finally, often no one person onthe pre-op team takes responsibili-ty for assessing emotional eating.Is it a nutrition issue? A psycholo-gist’s topic? Irrelevant? When teammembers are working out of differ-ent locations or not workingtogether at all, it is more difficultto build the rapport necessary toencourage disclosure. If assess-ments are brief or perfunctory, orworse, only focus on post-surgicalinstructions, disordered eatinghabits may not be picked up.

Emotional Eating: Why don’t wenotice emotional eating after sur-gery?

At a post-surgery support groupthat feels like a pep rally, thepatient who’s stress-snacking,bingeing, night-eating, or all of theabove, may not speak out. Ifthey’re not doing well, they may



FFrroomm tthhee CChhaaiirrcontinued from page 2

RD, will help us to work in a way that our clients willappreciate, and that will promote healthy change. Don’tmiss this one! A buffet lunch, a copy of Jessica’s text“The Eating Disorders Clinical Pocket Guide,” and 3CPEU come with the cost of registration. You need toregister on-line before September 20, 2007 for the bestdeal. Go to: www.eatright.org/ddpd-fnce.

Sunday, September 30th at 6:00 p.m. we invite youto join us in the Lobby Lounge at the DowntownPhiladelphia Marriott Hotel for our very first BHNmember social. We will have a special gift for the first10 BHN members to arrive and introduce themselves.Come for the conversation. Come for the fun. Justcome!

Monday, October 1st 10:30 a.m. to 1:00 p.m. isour Dietetics Practice Group Showcase. BHN officerswill be in Booth #18 to answer your questions, recordyour suggestions, get your input on redesign of ourBHN Web site and newsletter. We will have PsychiatricManual CDs for sale and BHN give-aways. And if youhave a friend who needs to become a BHN member,we will be recruiting new members too.

Tuesday, October 2nd is all about BHN’s PrioritySession. It begins at noon. You have found by now abrief article by Dean Elbe B.Sc. (Pharm), BCPP titled“Psychotropic Drug/Food Interaction.” We asked Deanto submit this piece so that you will have a taste of

what will occur during his presentation with ZanetaPronsky, MS, RD. Zaneta and Dean co-author a publi-cation that many of us reference routinely when weneed to look up food and medication interactions forour clients. Join us for this session to learn“Psychotropic Drugs/Food Interactions: What RDsNeed to Know.”

Officers, Harriet Cloud, MS, RD (NominatingCommittee Chair), Sharon Wojnaroski, MA, RD, (past-Chair) and I, will be attending the ADA House ofDelegates (HOD) session on Friday, September 27th, asyour representatives. We are very interested in observ-ing the HOD process and then working withProfessional Issues Delegates to identify BHN issuesthat need to be heard by the ADA House of Delegates.Mega Issues before the HOD on that day will includeHealth Disparities. This is indeed an issue pertinent tothe practice of BHN Dietetics Professionals. Which ofyour clients/patients have inadequate access to yourservices and what are their barriers to access? Emailme at [email protected]. I need to know. We willreport back to you on events of that day.

Welcome to Behavioral Health Nutrition! Let’s makeit a great year - together.

Paula Kerr MS, RD, CD

even drop out, preventing the sup-port that they desperately need.

They may seek support anony-mously on-line, where they mayfind sympathy, but also dangerousideas on how to “cheat” their post-surgery diets and continue emo-tional eating. It’s intimidating toadmit that you’re struggling withfood when you just had the surgerythat was supposed to be the solu-tion. Patients may feel like theyhave done something wrong, whenthey are not “succeeding” like theirpeers. And although the profes-

sional team may be as understand-ing as possible, our patients oftensee us as authority figures, anddon’t want to “disappoint” us withnews they are struggling. If theamount of food eaten for emotion-al reasons is not adequate to pro-mote noticeable weight gain,patients may suffer in silence with-out seeking assistance.

Emotional Eating: What canhappen if we miss it?

Some of our patients are obesefor reasons other than emotionaleating. These patients may have

complications post-surgery, but ofa different kind than emotionaleaters. The reported complicationsof post-surgery emotional eatingcan range from weight regain, withassociated comorbidities, to shame,depression and attempted suicide.On the way, patients may turn tosubstance abuse, smoking, promis-cuous behavior, compulsive shop-ping or other vices because theyaid brain chemistry in the waytheir eating used to do (13).

Patients with severe trauma his-tory or adverse sexual events may



even require hospitalization forpsychiatric needs when the protec-tive barrier of weight starts to thaw.Becoming more open to relation-ships, even though desirable on thesurface, can be scary to the personwho has been abused, ignored, ordisgraced by society (4).

What Can We Do to ImproveOutcomes?

Our review of literature suggest-ed that emotional eating is not nec-essarily a contraindication for sur-gery, but that emotional eaters mayneed more support post-surgerythan other patients. The problemremains that many emotional eatersdo not self-identify, and to date,there is no standard assessmentthat can be used in advance to pre-dict post-surgical success. Theresponsibility to identify emotionaleating, therefore, lies with any andall members of the treatment teamwho interact with patients.

Because the hallmark of emo-tional eating is the underlying, pri-mary issues, the main goal of treat-ment is to provide healthy alterna-tive outlets for handling these emo-tions. Patients do not need toresolve or eliminate all past andfuture negative emotions, but theymust learn to avoid non-hungereating as a response.

Some clues are available to guideprofessionals in detecting emotion-al eating in their patient popula-tion. Ideally, each team memberaddresses the possibility of emo-tional eating in his or her own way.The patient then has multipleopportunities to confide in the per-

son they relate to the best. If ques-tions and concerns are repeated bymore than one professional,patients may better appreciate therelevance of the answer and thecorresponding recommendations.Destigmatizing emotional eating ingroup or individual sessions canalso promote patient disclosure.Emotional eating IS NOT rare inour bariatric patient population. Itis common enough to deserve atleast a mention in all pre-operativeassessments and education. Evenwith all of our efforts, because ourpatients are often unaware of theiremotional eating, it may not berevealed until after surgery.

Post-surgery clues to emotionaleating include:

• Slow weight loss or failure to lose weight

• Gradual weight regain >10-15pounds from lowest post-sur-gical weight

• Rapid weight regain

• Resentment or lack of motiva-tion to follow dietary recom-mendations

• Maladaptive eating behaviors (increased and/or excessive intake of sweets, soups, calo-rie-containing liquids, soft foods, etc.)

• Reported vomiting, either spontaneous or self-induced

• Depression (look for crying, decreased self-care such as grooming, isolation, etc.)

• Reported increase in alcohol consumption

• Angry dissatisfaction with

surgery results or treatment provider(s) in the absence of medical or mechanical

complications

Once you realize that a patientis struggling with either emotionaleating or emotional barriers todietary compliance, recommendpsychological or behavioral coun-seling. In a supportive and non-accusatory manner, explain topatients that their surgery haschanged the way they are able tocope with stress, and assistancewith stress management is needed.If a patient is resistant to comply,suggest that counseling can besolution-focused or in a non-clini-cal setting and need not dwell onpast bad experiences.

If your clinic does not offer asupport group, and/or if a patient’sfinancial resources are limited,Overeaters Anonymous orAlcoholics Anonymous may beavailable in your community (seeTable 2 for resource information).Individual counseling may be pre-ferred for patients who need moreintense intervention, and can berecommended in addition to grouptherapy or support. The goal of anyof these therapeutic modalities is toseparate food and emotions, ratherthan eliminate one or both.

In the case where you choose todirectly provide your patient withguidance, and you are willing tospend the necessary time to coun-sel your patient, food records canbe a useful tool in determiningwhere emotions are interferingwith eating. A typical food diary of



simply what is eaten is not as help-ful as a more detailed journal ofsituational factors that come intoplay. For example, keeping track ofwhere, when, and with whomsomeone eats can identify linksbetween eating and outside factors,and listing emotional state beforeand after eating can identify whichemotions and triggers are mostlikely causing the problem.

Incorporating a rating of hungerbefore and after eating can helpidentify non-hunger eating whichmay be emotional. However, manypatients post-surgery haveimpaired perceptions of hungerand satiety, and should not neces-sarily be advised to follow thesesigns. The goal instead should beto identify if and when eating isclearly not nutrition-related, forexample when a patient is eatingout of anger, frustration, or simplyboredom.

Once emotional eating triggersare acknowledged, the next step isto separate the response from food.In other words, patients needsomething else to do when the urgefor comfort food arrives.Meditation or resting is preferredto television, as television adver-tisements frequently suggest eat-ing, and reading should be limitedto books, rather than magazines,for the same reason. Emotionaleating patients may not be accus-tomed to sitting still without anactivity. Distracting activities likeexercise, knitting, crossword puz-zles, or anything that keeps atten-tion off food, can be very helpful if

used consistently.

One project should be selectedin advance, as the stressful statethat induces emotional eating mayalso prevent clear thinking aboutalternatives. A support person mayalso be involved, as someonewhom your patient can call whenthe destructive eating strikes. Somepatients may find that a healthyexpression of feelings is suitableand relieving, such as writing in ajournal, artistic pursuits, listeningto music, scrapbooks or photoalbums, or writing a poem. Again,the key is to preplan an activity,and place the supplies in thekitchen or cupboard, wherever thepatient goes for their food. Thegoal is not to resolve all feelings,simply to avoid food, which cannothelp. If a patient finds that yourideas are still impossible to putinto practice, psychotherapy isonce again indicated to identifyemotional resistance to change.

In some cases, psychiatry iswarranted in addition to psy-chotherapy. Some patients may bemore willing to take medicine inlieu of counseling, which is a start.Other patients may be reluctant totake psychoactive medication, andwould rather pursue counselingalone.

Encourage your patient to takeadvantage of all possible treatmentmodalities; if you think psychiatryis warranted, refer to an appropri-ate professional. Because bothdepression and anxiety, individual-ly or in conjunction, can exacer-bate emotional eating and cause

weight gain, anti-depressant andanti-anxiety medications (some-times the same medicine, workingon both problems) can help dietarycompliance and promote continuedweight loss. The emotional lift ofweight loss can then keep the food-mood spiral moving in the rightdirection, and ultimately medica-tion may no longer be necessary.

However since emotional eatingcan stem from depression, anxiety,social insecurity, trauma, neglect,or abuse, medical managementmay be necessary long after bodyweight has normalized. In otherwords, our society may indicatethat depression is an effect of obe-sity, depression may actually be acause as well, and may requiretreatment regardless of weight.Patients who show signs of depres-sion, anxiety, insomnia, or post-traumatic stress before or afterbariatric surgery should be treatedfor these conditions. Althoughthese and other psychiatric condi-tions may be worsened by obesity,poor nutrition, and/or social conse-quences of being obese, that does-n’t mean they will completelyresolve simply by weight lossalone. No medications have beenapproved by the FDA specificallyfor the treatment of emotional eat-ing, so treatment must be individu-alized to each patient’s particularsymptoms.

In some cases, patients mayrefuse further care from you inresponse to denial that problemsexist. They may prefer to blameyou or their surgery “failure” than



explore the emotions that hurtthem so deeply. Some patients maynot attend follow-up visits becauseof their shame and their perception(whether deserved or not) that theywill be blamed or criticized fortheir substandard weight loss ortheir failure to comply with recom-mendations. You can repeat yoursuggestions for additional care, butan adult patient may choose not tofollow your recommendation.

In these cases, the most perti-nent goals are to try to provide asmuch emotional support as possi-ble and to prevent or minimize fur-ther weight regain. Maintain con-tact in whatever form possible,including, for example, phone callsor email. Leave the proverbial dooropen for a return to treatment ifand when the patient is ready.Encouragement and empathy in atone of compassion and acceptancecan prevent a discontented patientfrom turning away permanently.Expressing an understanding thatchanging is hard, even with theassistance of bariatric surgery, canhelp patients comprehend that thisis not “their fault,” but that choos-ing to change is their responsibili-ty. The behaviors that led to obesi-ty developed over years, andreversing them is no easy task.Although weight loss after the ini-tial post-surgery period may beslower or later than expected, it isstill possible with dietary andbehavioral compliance, even sever-al years down the road.

Emotional eating is hard oneveryone surrounding the person

who struggles. In a bariatrics prac-tice, you may become close to yoursurgery patients, and feel theweight of their struggle. When apatient with trauma or otherunseen issues has trouble withtheir surgery or weight loss, it’stempting to want to fix things forthem and help them feel better,lose weight, and succeed. Butunless you are willing to monitorpatients around the clock, ultimate-ly you will be relying on the indi-vidual’s motivation. Some of yourpatients may not be willing to takethe steps that only they can.

In these situations, you maybenefit from moral support. As atreatment provider, you are a rolemodel for your patients, like it ornot. Your patients take notice ofyour efforts to take care of your-self, emotionally and physically,not just the way you take care ofthem. In this vein, you may chooseto seek support from colleagues inyour facility, your town, or yourfield who have experienced similarchallenges. A support group inyour clinic to discuss difficultcases, or even simply taking anopportunity to vent, can providerelief from the stress that care-givers inevitably encounter.

Research remains inconclusiveabout the best course of action foraddressing emotional eating inbariatrics patients. For everyonewith emotional eating, there is adifferent set of circumstances thatcreated their pain, and a differentpath to well-being and health.Helping each patient find their

own way to heal by identifying andproviding resources that are appro-priate for their individual needs isthe best way to help both you andyour patients sleep soundly atnight.

1. Arnow B, Kenardy J, Agras W. The emotionaleating scale: The development of a measure toassess coping with negative affect by eating. Int JEat Disord 1995;18:79-90.

2. American Psychiatric Association. Diagnosticand Statistical Manual of Mental Disorders,Fourth Edition, Text Revision, 2000.

3. Bruce B, Wilfley, D. Binge eating among theoverweight population: A serious and prevalentproblem. JADA 1996;1:58-62.

4. Saunders R. “Grazing”: A high-risk behavior.Obesity Surgery 2004;14:98-102.

5. Yanovski S. Binge eating disorder and obesity in2003: Could treating an eating disorder have apositive effect on the obesity epidemic? Int J EatDisord 2003;34:S117-S120.

6. Pinaquay S, Chabrol H, Simon C, Louvet J,Barbe P. Emotional eating, alexithymia, andbinge-eating disorder in obese women. ObesityResearch 2003;11:195-201.

7. Van Hout, G, Verschure S, and Van Heck, G.Psychosocial predictors of success followingbariatric surgery. Obesity Surgery 2005;15:552-60.

8. Buser A, Dymek-Valentine M, Hilburger J,Alverdy J. Outcome following gastric bypass sur-gery: Impact of past sexual abuse. ObesitySurgery 2004;14:170-174.

9. Ray E, Nickels M, Sayeed S, Sax H. Predictingsuccess after gastric bypass: The role of psy-chosocial and behavioral factors. Surgery2003;134:555-563.

10.Gawdat K. Bariatric reoperations: Are they pre-ventable? Obesity Surgery 2000;10:525-529.

11.Hulme P. Physical and psychosocial symptoma-tology of female survivors of child sexual abuse.The University of Texas at Arlington 1992.

12.Grilo C, Masheb R, Brody M, Toth C, Burke-Martindale C, Rothschild B. Childhood maltreat-ment in extremely obese male and femalebariatric surgery candidates. Obesity Research2005;13:123-130.

13.Kleiner K, Gold M, Frost-Pined K, Lenz-Brunsman B, Perri M, Jacobs W. Body massindex and alcohol use. J Addict Dis 2004;23:105-118.


DDSSMM--IIVV RReesseeaarrcchh CCrriitteerriiaa ffoorrBBiinnggee--EEaattiinngg DDiissoorrddeerr

Recurrent episodes of binge eating, characterized by both of the following:(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that isdefinitely larger than most people would eat during a similar period of time and under similarcircumstances.(2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stopeating or control what or how much one is eating).The binge-eating episodes are associated with three (or more) of the following:(1) eating much more rapidly than normal(2) eating until feeling uncomfortably full(3) eating large amounts of food when not feeling physically hungry(4) eating alone because of being embarrassed by how much one is eating(5) feeling disgusted with oneself, depressed, or very guilty after overeatingMarked distress regarding binge eating is present.The binge eating occurs, on average, at least 2 days a week for 6 months.The binge is not associated with the regular use of inappropriate compensatory behaviors(e.g. purging, fasting, excessive exercise) and does not occur exclusively during the course ofAnorexia Nervosa or Bulimia Nervosa.

A

B

CD

E

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,Copyright 2000. (reprinted with permission from the American Psychiatric Association)

Table 1

Table 2

Locate a Support Group for Emotional Eating

Overeaters Anonymous: www.oa.orgEating Disorders Anonymous: www.eatingdisordersanonymous.orgAlcoholics Anonymous: www.alcoholics-anonymous.orgEating Disorder Referral Network: www.edreferral.com

RReeqquueesstt ffoorr NNoommiinnaattiioonnssGreetings to all members of

BHN! Opportunities for leadershipin BHN abound and as chairman ofthe nominating committee, I'mlooking for those of you who mightbe interested in running for one ofour offices: chair-elect, secretary,and nominating committee (three

names). The current leadership ofBHN is planning many activitiesfor members at FNCE this fall andcontinuing education eventsthroughout the year. If you areinterested in being in the leader-ship pool please e-mail me [email protected]. This will

help our committee as we begin thenomination process.

Thanks, Harriet H. Cloud, MS, RDBHN Nominating Committee

ChairPhone: 205-871-0582

*Chair (07-08)Paula D. Kerr, MS, RD303 Weston Ave Wausau, WI 54403-6879Home: (715) 845-6818Fax: (715) 845-6818Email: [email protected]

*Chair Elect (07-08)Jessica Setnick, MS, RD, LD6510 Abrams Road, Suite 302 Dallas, TX 75231Phone: (214) 503-7100Email: [email protected]

*Past Chair (07-08)Sharon M Wojnaroski, MA, RDPO Box 722 Farmington, MI 48332-0722Home: 989 739 7074 Cell: 248-345-5899Fax: (989) 739-5804Email: [email protected]

*Treasurer (07-09)Terry Anderson Girard, MS, RD, LDNPO Box 48Quincy, Ma. 02169Phone: (617) 293-9978 Email: [email protected]

*Secretary (07-08)Karen A. Jircitano, RD, LDNThe Resource Center880 East 2nd StreetJamestown, NY 14701Phone: (716) 661-1484Email: [email protected]

*Newsletter Editor AssistantDiane Spear, MS, RD, LD106 Craven CourtMannford, OK 74044Email: [email protected]: (918) 561-1351Home: (918) 865-7847

*Membership Chair (06-08)Kathryn (Kathy) Russell, MS, RD2534 Woodmont Dr. EWork: (715 /848-4600 Canton, MI 48188Phone: (734) 635-7771Work E-mail: [email protected] E-mail: [email protected]

Public Policy Chair (06-08)Andrea Shotton, MS, RD, LDN6718 Durango Dr Magnolia, TX 77354Email: [email protected]

*Newsletter Editor (07-08)Melody L Rankin, RD, LD14373 Glenview Drive Choctaw, OK 73020-8313Work: (405) 522-2085 Home: (405) 390-1539Home Email: [email protected]: [email protected]

Practice Manager Frances Austin, RD American Dietetic Association 120South Riverside Plaza, Suite 2000Chicago, IL 60606-6995Work: (800) 877-1600 ext 4813 Fax: (312) 899-4812Email: [email protected]

*Nominating Committee Chair (07-08) Harriet Cloud, MS, RD705 Fairfax DriveBirmingham, AL 35208-4411Home: (205) 871-0582Cell: (205) 515-1805Email: [email protected]

RREESSOOUURRCCEEPPRROOFFEESSSSIIOONNAALLSSDevelopmental Disorders (05-08) Paula Cushing, RD 7015 Ellendale Drive Brentwood, TN 37027Phone: (615) 231-5441 Email: [email protected]

Eating Disorders (07-10) Roberta Pearle Lamb, MPH, RDWalden Behavioral Care 9 Hope AvenueWaltham, MA 02453 Work: (781) 647-6789Email: [email protected]

Substance Abuse (07-10) Ellen Tobias, MA, RDGreater Bridgeport Community Mental Health Center Bridgeport, CT 06610 Work: (203) 551-7534Email: [email protected]

Psychiatric Disorders (06-09) Linda Venning, MS, RDHawthorn Center 18471 Haggerty RdNorthville, MI 48167 Work: (248) 735-6711Email: [email protected]

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