Journal of Human Nutrition and Dietetics
RESEARCH PAPER
Nutrition and dietetic practice in eating disorder
management
S. Hart,* J. Russell*à & S. Abraham
*Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
Department of Obstetrics and Gynaecology, University of Sydney, New South Wales, Australia
àDepartment of Psychological Medicine, University of Sydney, New South Wales, Australia
Keywords
dietitian, eating disorder, normal eating,
nutrition, refeeding, weight.
Correspondence
S. Hart, Level 2, Missenden Psychiatric Unit,
John Hopkins Drive, Camperdown,
NSW 2050, Australia.
Tel.: +61 2 8587 0200
Fax: +61 2 8587 0208
E-mail: susan.hart@sswahs.nsw.gov.au or
sd_hart@hotmail.com
doi:10.1111/j.1365-277X.2010.01140.x
Abstract
Background: This review examines the current literature that is available on
nutrition and dietetic practice in the treatment of eating disorders. Evidencebased guidelines on nutrition and dietetic practice in the management of eating
disorder patients are lacking, as is detailed information on how to implement
existing recommendations into day-to-day practice.
Methods: A search of databases was undertaken, with articles on nutrition and
eating disorders being reviewed for strength of evidence, content and relevance
to dietetic practice. Core dietetic skills used at the graduate level, such as dietary assessment, were not included in the literature review.
Results: There were a total of 61 references reviewed that discussed nutrition and dietetic practice in the management of eating disorder patients.
Most papers were descriptive papers, with few examining the effectiveness of
nutrition intervention. Three papers were surveys that assessed the professional needs and challenges of dietitians who work with eating disorder
clients.
Conclusions: Dietetic practice in the treatment of eating disorder patients is
not well defined. Most publications are descriptions of practice, with few evaluating the effectiveness of dietetic work. Dietitians need to move from the clinical arena alone and become more involved in research, evaluating practice and
defining a gold standard of nutritional treatment strategies that are best delivered by the dietitian. There is also a need for manualised approaches that can
be prospectively examined.
Introduction
Literature and practice guidelines on anorexia nervosa
[Beumont et al., 2004; Gowers et al., 2004; Winston et al.,
2005; American Dietetic Association, 2006; American
Psychiatric Association, 2006; Wakefield & Williams,
2009] refer to the importance of nutrition intervention in
the treatment of eating disorder patients with the core
goals of initial treatment in eating disorder patients to:
l
l
l
restore weight;
restore nutrition, and;
aim for a return to normal eating.
144
Despite this advice, evidence-based guidelines on managing the nutritional needs of eating disorder patients are
lacking, as are details of precisely what nutrition intervention is, or how to implement existing recommendations
into day-to-day dietetic practice.
Dietitians have the skills to advise patients, multidisciplinary colleagues, health professionals and carers on
the above goals. Because under-nutrition and its sequelae
are a major consequence of the disorder and initial treatment involves the restoration of nutrition, it is surprising
that there is limited evidence on which to direct clinical
practice. Nutrition intervention is suggested to have been
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S. Hart et al.
neglected because there is the assumption that the disturbance in eating behaviour is a secondary feature of the
illness and that the abnormal eating behaviours will
correct themselves once the patient has received the
necessary psychotherapy (Beumont et al., 1988). The side
effects of starvation in anorexia nervosa must be treated
before patients can be involved in meaningful psychotherapy and counselling, and not regarded as features that
will correct themselves spontaneously with refeeding
(Salvy & McCargar, 2002). Reviews of the treatment of
eating disorders have reported that insufficient attention
has been paid to addressing the optimal nutritional
approaches in treatment (Bulik et al., 2007) and nutrition
intervention alongside other treatment modalities is
recommended because there is insufficient evidence to
support any of the psychotherapies alone as having an
impact on weight change in people with eating disorders
(Hay et al., 2003).
The National Institute for Clinical Excellence (Gowers
et al., 2004) provide guidance on nutrition intervention
and a thorough review of eating disorders, although this
has limited insights on dietetic practice in eating disorder
management. Unfortunately, the dietetic profession was
not represented on The Guideline Development Group
convened by The National Collaborating Centre for
Mental Health.
A study examining nutrition knowledge of 65 clinicians
working with eating disorder patients demonstrated that
dietitians have the best nutritional knowledge of the clinician groups, and there was a poor level of nutritional
knowledge in nondietitian healthcare professionals working with eating disorder patients, even though nutrition is
central to the pathology and treatment of this disorder
(Cordery & Waller, 2006). They recommend that therapists have sufficient basic nutritional knowledge to be able
to identify distortions in their patients and therefore
effectively provide nutritional intervention (Cordery &
Waller, 2006). The involvement of a dietitian, within a
multidisciplinary framework, is of great benefit in the
treatment of eating disorders (Kirk, 1993).
A review of nutrition management concluded that the
degree which patient’s food preferences are accommodated in refeeding protocols used at treatment centres
varies, reflecting the clinical impressions and anecdotal
experience of those who developed the programme (Rock
& Curran-Celentano, 1996). Inappropriate nutritional
management may play a role in the protracted course
experienced by some patients and the development of
sequelae such as cognitive dysfunction and bone loss
(Rock & Curran-Celentano, 1994).
Another concern for dietitians working in eating disorders is the lack of consensus or working definition of
what ‘normal eating’ is. The authors are aware of only
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Nutrition intervention and eating disorders
one published comprehensive description of normal eating (Abraham & Llewellyn-Jones, 2001) and, in the eating
disorder literature, there are limited descriptions of ‘normal eating’, which are rarely referenced. For example, a
description of ‘Nutrition education and advice’ described
as part of Specialist Supportive Clinical Management for
anorexia nervosa mentions ‘normal eating’ 16 times in
four paragraphs (McIntosh et al., 2006) but does not reference its definition of ‘normal eating’. There is little
research that defines normal eating, and the statement is
more often used in the prescriptive/evaluative sense than
in the descriptive/statistical sense (Polivy & Herman,
1987). Normal eating is defined by ‘what it is not’ (i.e. it
is not the eating behaviors of eating disorder patients).
This is a concern if ‘normal’ eating, behaviour and weight
are the aim of what dietitians are advising patients to
work towards. It is necessary to define and expand the
role of the clinical dietitian as a key team member in
treatment and conduct more research on nutritional
treatment strategies (Krey et al., 1989).
The present review examines the literature on nutrition
and dietetic practice in the treatment of eating disorders,
aiming to review the strength of evidence for nutrition
intervention, as well as how clinically relevant the current
literature is to dietetic practice.
Materials and methods
A search of databases was undertaken using Medline,
AMED and PsycInfo with the keywords dietitian, diet,
refeeding, normal eating, eating disorder, anorexia and
bulimia nervosa, nutrition counselling, inpatient, treatment, gain, weight and nutrition in various combinations.
The searches were conducted between 2002 and 2010, with
the last search conducted on 20th September, 2010. A
snowballing method was used to find other relevant material (i.e. references from articles were used to find other relevant articles). A hand search was undertaken of book
chapters in edited eating disorder texts, dietetic texts, as
well as key dietetic and eating disorder journals. Articles
were reviewed for specific detail or instruction of dietetic
practice, strength of the evidence and relevance to dietetic
practice. An attempt was made to rank the articles by the
National Health and Medical Research Council (NHMRC)
definition of evidence categories from Level 1 to IV
(NHMRC, 2000); however, the majority of articles did
not meet the NHMRC evidence levels, so the American
Psychiatric Association method of ranking treatment
literature on eating disorders was used (APA, 2006). This
method gave multiple categories from A to G, which were
further rated into categories as ‘strong’ (randomised controlled trial, nonrandomised prospective clinical trials),
‘moderate’ (observational cohorts of treatment, including
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Nutrition intervention and eating disorders
retrospective examinations of treatment with a control
group) or ‘weak’ (position papers, literature reviews, case
studies, surveys or text books reviews) (Table 1). Only
articles in English were reviewed. Papers that described
general nutrition rehabilitation or intervention without
details of implementation or relevance to dietetic practice
were excluded. Core skills such as dietary assessment were
also not included in the literature review because they are
learnt during basic dietetic education, and it has been
shown that eating disorder dietitians already feel well
trained in these areas but poorly prepared for eating
disorder nutrition counselling (Cairns & Milne, 2006).
Results
A total of 80 papers or texts were reviewed of which 61
were included in this review. Nineteen papers were
excluded because the advice was too general and not specific to dietetic practice. There were 50 papers from journals, six from text books, and five position papers or
practice guidelines. Thirty of the papers had a dietitian as
the primary author, 11 with a dietitian as a co-author,
eight where no dietitian was included as an author, and
12 papers in which it was unknown if there was a dietitian as author credentials were not included in the article.
Most papers were descriptive papers, with four examining effectiveness of nutrition intervention (O’Connnor
et al., 1988; Laessle et al., 1991; Serfaty et al., 1999;
Waisberg & Woods, 2002). In total, there were seven surveys of which three were highly relevant to dietetic
practice because they assessed the professional needs and
challenges of dietitians working with eating disorder clients (Whisenant & Smith, 1995; Cairns & Milne, 2006;
Hart et al., 2008).
There were only seven articles that were rated as ‘strong’
evidence, 14 rated as ‘moderate’ evidence, and 40 rated as
‘weak’ level of evidence because they were largely literature
reviews and expert opinions (n = 20), position papers or
text books. Forty-one papers are included in Table 2
because they were rated the most relevant to dietetic practice and provided specific details on dietetic practice strate-
gies. These are listed in 12 key areas: (1) Meal planning; (2)
Accurate nutritional information; (3) Normal eating; (4)
Psycho-education; (5) Stopping weight losing behaviours;
(6) Nutrition counselling, developing rapport and the therapeutic alliance; (7) Behavioural strategies; (8) Practical
and social eating skills; (9) Appetite regulation; (10) Dietary rules and guidelines during inpatient treatment; (11)
Refeeding; and (12) Meal supervision (Table 2).
The role of the dietitian and areas of practice
Several studies comment on the core goals of nutrition
intervention with the eating disorder patient as separating
food and weight-related issues from emotional issues and
assisting patients to make connections between the
amount and variety of food they eat, and their state of
health and energy (Williams & O’Connor, 2000). Herrin
(2003) suggests that nutrition counselling is eclectic in
that it employs cognitive behavioural, interactional, relational and educational techniques. It has been suggested
that dietitians need to solidify, define and expand the role
of the dietitian as a key team member; offer specialised
training in counselling techniques; develop standards of
care and quality assurance parameters; conduct research
on nutritional treatment strategies and cost-effectiveness
of nutrition services; and create educational strategies and
tools that are specific to the treatment goals of eating disorders (Krey et al., 1989).
Team work
A key point emphasised in the literature is that dietitians
should work in teams, and not be sole practitioners during treatment (Thomas, 2000; ADA, 2006; Wakefield &
Williams, 2009), and they should also have an understanding of underlying dynamics at work with eating disorder patients (Cairns & Milne, 2006). When working
with teams, the dietitian needs to have good understanding of professional boundaries, and recognise and appreciate the specific tasks and responsibilities of each team
member (ADA, 2006; Cairns & Milne, 2006).
Table 1 Levels of evidence for nutrition and dietetic papers (APA, 2006)
Strong
Moderate
Weak
Systematic review or meta-analysis (n = 0)
Randomised control trial double blinded (n = 1)
Randomised control trial (n = 3)
Prospective clinical trial not randomised (n = 3)
Prospective observational cohort – no
control (n = 9)
Retrospective treatment cohort (n = 5)
Position papers or guidelines (n = 5)
Expert opinion or literature review (n = 20)
Textbook (n = 6)
Case study (n = 2)
Survey professionals (n = 5)
Survey eating disorder patients (n = 1)
Survey community (n = 1)
Total = 7 (11%)
Total = 14 (23%)
Total = 40 (66%)
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Table 2 Suggestions for nutrition intervention from expert clinicians
1 Meal planning:
Focus on ‘when’ rather than ‘what’ the patient eats (Latner & Wilson, 2000; Herrin, 2003) and establish a regular pattern of meals and snacks
(Herrin, 1999; Williams & O’Connor, 2000; Salvy & McCargar, 2002; Winston et al., 2005)
Plan the introduction of a variety of foods including ‘binge foods’ and ‘forbidden’ foods (Willard et al., 1983; Woo, 1986; O’Connnor et al.,
1988; Laessle et al., 1991; Whisenant & Smith, 1995; Latner & Wilson, 2000; Salvy & McCargar, 2002; ADA, 2006; Ashley & Crino, 2010)
Use food exchange lists, food models and portion controlled foods to ensure a varied choice of foods (Willard et al., 1983; Woo, 1986; Rock &
Yager, 1987; Kirk, 1993; Thomas, 2000; Salvy & McCargar, 2002; Herrin, 2003)
Make changes in a step wise fashion (Herrin, 2003)
Include fats (Woo, 1986) from dressings, margarine, nuts, seeds and avocado (Rock & Yager, 1987)
Include a written outline of several ‘model’ days (Herrin, 1999)
Assist patients to be mechanical and establish an organised approach to eating that gives them confidence (Herrin, 2003)
Help families formulate healthy appropriate guidelines for family meals (Williams & O’Connor, 2000)
2 Accurate nutritional information on:
Metabolism, energy requirements, determinants of body weight (O’Connnor et al., 1988; Laessle et al., 1991; Kirk, 1993; Merriman, 1996;
Thomas, 2000; Williams & O’Connor, 2000; Herrin, 2003; ADA, 2006; Hart et al., 2008)
Nutrition misinformation (Laessle et al., 1991; Williams & O’Connor, 2000; Herrin, 2003; ADA, 2006; Ashley & Crino, 2010)
Individual nutrition needs and how these change during the recovery process (Williams & O’Connor, 2000)
Making connections between the amount and variety of food eaten, and the state of health and energy (Williams & O’Connor, 2000)
Normal calorie and fat intake (Herrin, 1999)
Dental health and gut function (Hart et al., 2008)
Calcium intake and osteoporosis (Herrin, 2003; Hart et al., 2008)
Fluid intake (Hart et al., 2005)
Interpreting nutrition labels according to general principles of healthy eating rather than in excessive detail (Ashley & Crino, 2010)
3 Advice on normal eating:
Avoid dietary products as they reinforce a belief that weight will be gained on less amounts of food than others, are counterproductive for
weight gain in anorexia nervosa (AN) and keep bulimia nervosa (BN) locked in the belief that they have to diet (Beumont et al., 1988;
O’Connnor et al., 1988; Beumont et al., 1997a; Williams & O’Connor, 2000; Herrin, 2003; Winston et al., 2005)
Eat for enjoyment and health, and aim for spontaneous and flexible eating behaviours (O’Connnor et al., 1988; Williams & O’Connor, 2000;
Abraham & Llewellyn-Jones, 2001)
Focus on what others eat and what normal eating really means rather than an idealised view of the perfect diet (Williams & O’Connor, 2000)
Restrict eating to one room in the house, sit down when eating and do not engage in other activities when eating (Rock & Yager, 1987; Salvy
& McCargar, 2002)
Develop sensitivity to cues for eating that most people follow such as appetite, time of day, social situation and visual appeal (Beumont et al., 1988)
Use appropriate utensils and eat at a moderate pace (Salvy & McCargar, 2002)
Avoid measuring food (O’Connnor et al., 1988)
Eat with others where possible (Beumont et al., 1997a)
4 Psycho-education:
Biological and psychological effects of starvation (Laessle et al., 1991; Williams & O’Connor, 2000; ADA, 2006; Hart et al., 2008)
Addressing irrational and negative beliefs about eating, weight and shape, and correct misconceptions about body weight regulation (Williams
& O’Connor, 2000; ADA, 2006)
Consequences of binge eating and purging (Kirk, 1993; Williams & O’Connor, 2000; ADA, 2006; Hart et al., 2008)
Help overcome guilt associated with eating fattening foods (Williams & O’Connor, 2000)
Educating patients about the disadvantages of avoiding food and encouraging patients to gradually expand their eating experiences (Ashley &
Crino, 2010)
5 Advice on stopping weight losing behaviours:
Help patients refrain from restrictive dieting, break the diet/binge/purge cycle in BN and restore a healthy weight in AN (O’Connnor et al.,
1988; Williams & O’Connor, 2000)
Avoid excessive exercise (Rock & Yager, 1987; O’Connnor et al., 1988)
Comment on stability of weight despite improved eating behaviour (Laessle et al., 1991)
Support patients to accept and maintain a healthy body weight (Williams & O’Connor, 2000)
6 Nutrition Counselling, developing rapport & the therapeutic alliance:
a. Engagement
Show genuine concern for the client (Omizo & Oda, 1988; Herrin, 2003)
Aim for a trusting and open relationship that assists the patient to begin to share their fears and abnormal behaviours, and promotes trust
in the dietitian’s guidelines for change (Woo, 1986; Beumont et al., 1997a; Williams & O’Connor, 2000)
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Table 2 (Continued)
Establish a supportive rather than confrontational relationship (Herrin, 2003)
Remain non judgemental in dealing with dietary non compliance and manipulative behaviours (Woo, 1986)
b. Show empathy (Omizo & Oda, 1988)
Have an understanding of the underlying psychological beliefs (Willard et al., 1983; O’Connnor et al., 1988; Omizo & Oda, 1988)
Acknowledge how difficult it is to make changes in food and exercise behaviours (Herrin, 1999)
c. Collaborate with the patient (Herrin, 1999)
Involve the patient actively in food planning and decisions (Willard et al., 1983; Rock & Yager, 1987; Herrin, 1999)
Help foster self decision in regards to food (Baird & Sights, 1986)
d. Motivational strategies
Offer knowledge through handouts, articles and other information that give the client the choice of accepting the information (Baird &
Sights, 1986)
Discuss barriers for behavioural change and examine the pros and cons of change (Herrin, 2003; Cairns & Milne, 2006)
e. Goal setting (Whisenant & Smith, 1995; ADA, 2006)
To leave each session with a goal they are sure they can accomplish (Herrin, 1999)
Behavioural assignments that the patient commits to fulfilling between sessions that are specific, detailed and relevant to the patient (Herrin,
2003)
Make it clear how each goal benefits the patient (Herrin, 2003)
f. Skills to demonstrate
Maintain a sense of humour (Woo, 1986; Omizo & Oda, 1988; Cairns & Milne, 2006)
Be confident, firm, consistent and authorative (Beumont et al., 1997a; Herrin, 2003)
Remain calm and philosophical about the patient’s dilemmas (Herrin, 2003)
Refrain from power struggles (Herrin, 2003)
Be persuasive and curious (Herrin, 1999)
Establish credibility (Herrin, 2003)
Be warm, open, patient, and encouraging (Omizo & Oda, 1988)
g. Other strategies
Explore the patients emotional relationship with food, and their food fears (Williams & O’Connor, 2000)
Use problem solving techniques (Whisenant & Smith, 1995; Herrin, 2003)
Be on the alert for the patient who uses nutrition counselling to focus on psychological issues (Herrin, 1999)
Inquire as to why specific dietary information is requested when considering the function and usefulness of the material, so that appropriate
recommendations can be given, and to avoid giving patients further reason to exclude foods (Ashley & Crino, 2010)
7 Behavioural strategies:
Avoid weighing between sessions (O’Connnor et al., 1988; Herrin, 1999)
Develop a hierarchy of foods/eating situations that the patient has been avoiding from the least to most anxiety provoking with graded
exposure to these foods (Ashley & Crino, 2010)
Use self monitoring to identify links between emotions (i.e. poor self-esteem, fear of losing control) and food that can be dealt with in more
depth during psychotherapy (Williams & O’Connor, 2000)
For reducing binge eating
Limit access to food that encourages binge eating (Laessle et al., 1991; Hsu et al., 1992; Salvy & McCargar, 2002)
After an episode of binge eating return to the prescribed meal plan or the next scheduled meal or snack as soon as possible (Herrin, 1999;
Salvy & McCargar, 2002)
Limit the amount of food available during the meal and discard leftovers (Salvy & McCargar, 2002)
Avoid missing meals or snacks (Salvy & McCargar, 2002)
Avoid eating from large packets (O’Connnor et al., 1988)
Teach healthy coping behaviours to regain control between situations and eating response (Laessle et al., 1991)
8 Practical and social eating skills:
Practice going to a restaurant or café, eating in a group and for special occasions (Laessle et al., 1991; Hsu et al., 1992; Kirk, 1993; Hart et al.,
2008; Ashley & Crino, 2010)
Provide advice on shopping, meal preparation, cooking; and the practicality of meal plans (Laessle et al., 1991; Hsu et al., 1992; Merriman,
1996; ADA, 2006; Hart et al., 2008; Cockfield & Philpot, 2009; Ashley & Crino, 2010)
To help patients understand eating in its social context, and the relationship between food and culture (Ashley & Crino, 2010)
9 Appetite Regulation:
Relearn/increased attention to normal hunger and satiety cues (Sunday & Halmi, 1996; Williams & O’Connor, 2000)
Recalibrate appetite so it accurately reflects biological needs (Herrin, 2003)
10 Dietary rules and guidelines during inpatient treatment:
Have a food environment that is planned and secure to attain a sense of control and consistency (Kreipe & Kidder, 1986)
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Table 2 (Continued)
Place limitations on foods that patients may refuse to eat
Three to five dislikes permitted (Rock & Kaye, 2001; Herrin, 2003; Hart et al., 2008)
Differentiate true dislikes from anorexic aversions (Huse & Lucas, 1983)
Limit dietary exclusions such as veganism (Rock & Kaye, 2001; Winston et al., 2005; Hart et al., 2008)
Acceptance of food allergies only when medically indicated (Hart et al., 2008)
Advising patient to not bring their own food and drinks into hospital (Beumont et al., 1988; Hart et al., 2008)
Discourage the over use of caffeinated beverages (Rock & Yager, 1987)
Encourage the consumption of a varied diet that includes energy-dense foods and avoidance of energy dilute foods, low fat condiments,
chewing gum and other strategies to manage hunger (Winston et al., 2005; Schebendach et al., 2008)
Avoid prescribing excessive amount of foods (Huse & Lucas, 1983; Woo, 1986)
If dental disease is severe, then soft foods may need to be provided, and limit acidic foods, salty foods or foods at extreme temperatures
(Winston et al., 2005)
11 Refeeding:
Introduce food gradually with small frequent feedings to reduce sensations of bloating (Rock & Yager, 1987; Davies & Jaffa, 2005; Winston
et al., 2005)
Increase energy with a variety of regular food with sufficient amounts of micronutrients (Rock & Yager, 1987; Winston et al., 2005)
Reduce the use of raw fruits and vegetables as a result of them being filling, not calorie dense and (because of) their effect on delaying gastric
emptying. (Woo, 1986; Rock & Yager, 1987; Herrin, 2005)
Use whole grains and bran to aid constipation (Woo, 1986; Rock & Yager, 1987)
Advise patients that they will feel overly full for 2–3 weeks as their body adjusts to food (Winston et al., 2005) and encourage eating regardless
of fullness (Woo, 1986; Herrin, 2005)
Yogurt may improve immunological markers independent of weight gain (Nova et al., 2006)
Avoid excessive sodium to limit the risk of fluid and electrolyte overexpansion (Winston et al., 2005)
Provide high structure, low stress, support and encouragement (Fernstrom et al., 1994)
12 Meal supervision:
For one hour after each meal (Krahn et al., 1993; Couturier & Mahmood, 2009)
Set firm expectations about what must be eaten in a set period of time (Couturier & Mahmood, 2009)
Target obsessional behaviour (i.e. precise food measurement) and table manners (i.e. eating with fingers, unusual food combinations, picking
at food, eating small amounts, inappropriate movement in the dining room, showing distaste for food) (Wilson et al., 1985; Beumont et al.,
1988)
The reintroduction of food may be facilitated by therapist modelling (Salvy & McCargar, 2002) and clinicians’ own healthy attitudes about
eating and weight are an important part of the social learning experience (Ashley & Crino, 2010)
Encouragement and reassurance from other patients and staff members can overcome initial resistance to eating (Beumont et al., 1988)
Provide empathy and understanding of the patient’s struggle, at the same times as encouraging the consumption of food (Couturier &
Mahmood, 2009)
Challenges for the dietitian
Challenges of working with eating disorder patients were
identified in several studies as:
The difficulty of conducting meaningful nutrition
counselling sessions with a starving individual as a certain
amount of nutritional restitution is necessary before the
individual can internalise knowledge during the nutrition
counselling process (Omizo & Oda, 1988).
l The dietitian may be viewed with some fear and mistrust by the anorexia nervosa individual (Woo, 1986).
l Techniques that encourage the individual with anorexia
nervosa to eat and gain weight usually provoke anxiety
and resistance, so the dietitian must be prepared with an
array of interventions to assist the individual who displays
resistance (Omizo & Oda, 1988).
l Being aware that once eating disorder coping strategies
are removed, patients may become more emotionally disl
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turbed as they become aware of the underlying issues
(Williams & O’Connor, 2000).
l Change may be accompanied by marked anxiety and
prominent defensive manoeuvres, and patients can protest, ignore, sabotage or dispute advice, use bargaining,
manipulation, negativism and opposition behaviours
(Krey et al., 1989).
l Dealing with dietary noncompliance (Woo, 1986).
l Being on guard about becoming too invested in the
process of change or imposing the therapists own values
about food and exercise on the patient (Herrin, 2003).
What is the evidence for nutrition intervention?
There were four papers that examined evidence for the
effectiveness of nutrition intervention (NI). One paper
was a comparison of a NI and stress management group
with 55 bulimia nervosa patients (Laessle et al., 1991).
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The NI group showed a more rapid reduction in binge
eating, a more rapid increase in calories, improved abstinence from vomiting compared to stress management,
and was successful in modifying restrained eating behaviours and interrupting bulimic behaviours. Depressive
symptoms in most patients improved in parallel to eating
behaviour, although NI was less effective in changing feelings of ineffectiveness, interpersonal distrust and anxiety.
This supports recommendations of dietetic practice to
not work in isolation, to know professional boundaries
and not attempt intervention with psychological schema’s,
such as ineffectiveness, which are the core goals of
psychological intervention (Herrin, 2003; ADA, 2006;
Wakefield & Williams, 2009). This study was randomised
and a manualised treatment delivered over two sites.
Another study (O’Connnor et al., 1988) demonstrated
effectiveness in a retrospective review of a NI only intervention of 18 bulimia nervosa patients who completed
10 NI sessions. Twelve patients ceased all bulimic behaviours, 18 ceased laxatives, and there was a significant
reduction in binge-eating from 5.2 to 0.6 days per week,
and self-induced vomiting from 3.1 to 0.2 days per
week, with no overall change in before and after body
weight.
Serfaty et al. (1999) are frequently quoted as evidence
of dietary intervention being ineffective (Sorrentino et al.,
2005; McIntosh et al., 2006) because, in a randomised
study of 40 anorexia nervosa patients, 100% of the dietary
group dropped out within 3 months of treatment compared with a cognitive therapy group. The cognitive group
was a manualised treatment and appeared to include a NI
component in addition to 20 sessions of cognitive therapy.
The dietary treatment group with 10 participants was not
a manualised treatment, appears to have been designed as
the placebo control group rather than an active intervention, and the intervention was not referenced. It could be
interpreted as a purely education approach without a
counselling component rather than nutrition intervention,
which has been suggested in other studies as likely to be
unsuccessful in anorexia nervosa patients who are fearful
and ambivalent about weight gain and view the dietitian
with mistrust (Omizo & Oda, 1988), and which is not sufficient to change fear and guilt about food (Woo, 1986).
The study may have been affected by the small numbers
randomised and it was likely that it was under-powered
(Hay et al., 2003). Practice guidelines for dietitians
emphasise the importance of nutrition counselling not
being the sole treatment in eating disorders as has been
trialled in some studies (Serfaty et al., 1999; SundgotBorgen et al., 2002).
A group therapy treatment that integrated dietetic
intervention with psychological therapy for 8 weeks found
a statistically significant increase in weight, changes in the
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Eating Attitudes Test, increase in energy, fat, protein,
amount and variety of food consumed (Waisberg &
Woods, 2002). The authors comment that the combination of treatment was the key element of success of the
programme. There were four papers on NI rated as having a strong level of evidence because of the more rigorous study design employed compared to the other papers
reviewed, although these were not rated as particularly
relevant for dietetic practice (Wilson et al., 1985;
Beumont et al., 1997b; Hsu et al., 2001; Sundgot-Borgen
et al., 2002).
Professional development
Three surveys of dietitians have been conducted which
attempt to define nutrition and dietetic practice (Whisenant & Smith, 1995; Cairns & Milne, 2006; Hart et al.,
2008). One study found that 55 of 94 of respondents
were concerned about identification of the most effective techniques for nutrition intervention and counselling in short and long-term therapy, as well as the need
for objective data about the value of therapy provided
by dietitians (Whisenant & Smith, 1995). The ADA recommends advanced level training from a combination
of self study, continuing education programme and
supervision from another experienced dietitian (ADA,
2006). Cairns reported that dietitians tended to train
themselves via reading, mentorship, conferences and
courses, rather than through formal training (Cairns &
Milne, 2006).
Discussion
To the authors’ knowledge, there has been no review of
the specifics and details of dietetic practice in the treatment of eating disorder patients. There are many
descriptions of clinical practice in this area but no integration of this information, which is an essential step
before further research can be undertaken. It is important to establish a baseline of practice before ideas can
be tested and a strong evidence base can be produced.
Most studies authored by dietitians were descriptions of
practice with few examining effectiveness, and only half
of the papers reviewed had a dietitian as the primary
author.
It is worth noting that of the seven papers that were
rated to have a strong level of evidence as a result of their
study design, only one was rated as being highly relevant
and two moderately relevant to dietetic practice. Of 41
papers included in the summary of key dietetic practice
areas in Table 2, 29 were rated as ‘weak evidence’ because
they were referenced from position papers, expert opinion, text books, case studies and surveys. However, it is
ª 2011 The Authors. Journal compilation ª 2011
The British Dietetic Association Ltd. 2011 J Hum Nutr Diet, 24, pp. 144–153
S. Hart et al.
important to note that ‘weak evidence’ that does not arise
directly from scientific investigation comprises an important source of information when evidence is lacking
(NHMRC, 2000).
Dietitians should be the provider of nutrition intervention in eating disorders because medical nutrition
therapy is the core skill of the dietitian, it is the role
that we are qualified for (ADA, 2006), and dietitians are
able to provide the most accurate information to clients
(Williams & O’Connor, 2000; Cordery & Waller, 2006).
As stated by Cordery, the role of the dietitian therefore
extends further than advising the patient because it is
necessary also to educate other clinicians (Cordery &
Waller, 2006).
The dietitian is reliant on more experienced psychiatric
and psychological colleagues, and can develop competent
counselling skills as a result. The process of supervision,
although not unique in psychological medicine, is not
usual dietetic practice even though mentoring is more
common, and shown to be highly valued as a learning
route (Cairns & Milne, 2006). It may benefit dietitians
working with eating disorder patients to seek out formal
supervision from a more experienced dietetic or multi
disciplinary colleague, or therapist working in eating disorders. The benefits of supervision, regular case meetings
and discussions with the treating team, as well as attendance at all case reviews, cannot be emphasised enough
as being possibly one of the most significant ways to
broaden knowledge and skills in the treatment of eating
disorders.
The evidence shows that nutrition counselling is not
well defined, with most practitioners learning on the job
(Cairns & Milne, 2006), knowledge and practice in this
area is highly variable (Whisenant & Smith, 1995; Hart
et al., 2008), and dietitians feeling ill prepared to work in
this area (Cairns & Milne, 2006).
It is recommended that dietitians need to move from
descriptions of clinical practice to prospectively designed
studies, initiate further research on evaluating the effectiveness of dietetic work, and produce manualised treatments that have the potential to be evaluated, in the same
way that cognitive behaviour therapy (CBT) has been so
successfully evaluated.
A treatment trial should be undertaken that evaluates
traditional components of treatment such as CBT, with
one arm having a manualised nutrition and dietetic
counselling component (delivered by an experienced
dietitian) being compared with a CBT group without
the nutrition and dietetic component, and would provide a valuable contribution to the literature. Clinical
trials and evaluations of practice that are led by dietitians will likely result in research that is more relevant
to dietetic practice and will help to provide a stronger
ª 2011 The Authors. Journal compilation ª 2011
The British Dietetic Association Ltd. 2011 J Hum Nutr Diet, 24, pp. 144–153
Nutrition intervention and eating disorders
evidence base to support nutritional treatment strategies
for eating disorder patients that are best delivered by
the dietitian.
Conflict of interests, source of funding and
authorship
The authors declare that they have no conflicts of interest.
No funding is declared.
SH conducted the literature search and wrote the paper.
SA and JR made revisions to the manuscript. All authors
critically reviewed the manuscript and approved the final
version submitted for publication.
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