Weight management
Experiences in practice The practical integration of dietetics and cognitive behavioural therapy in weight management
Alison Holloway Specialist Community Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust
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Alison has been an NHS Dietitian for over 20 years. Her primary interest is working with overweight patients with psychological and behavioural eating problems and who are struggling with traditional care.
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I have been a dietitian for over 20 years and in that time, I have seen many changes in practice. One of the biggest has been the move away from a medical model of care, to using increasingly advanced counselling and motivational skills. I was fortunate enough to study for a year with Sheffield Hallam University on a foundation level 6 Cognitive Behavioural Therapy (CBT) course. The basis of CBT is looking at the interaction between thoughts, feelings, physical symptoms and behaviours, already an integral part of the dietetic role. Once I had completed this course, a job became available as a CBT Weight Management Dietitian for the new Sheffield Weigh Ahead service, which was a tier 3 weight management service. As this was a new service, there were opportunities to create novel ways of working. Supervision was available with the team psychologist to support the development of my CBT work. We agreed early on which patients would come to me and which to psychology, although there was overlap and transfer between us. My client group was primarily made up of those with a history of eating disorders or disordered eating, complex food behaviours and beliefs, emotional connections and emotionally driven behaviours around food and weight, needing dietary support alongside behavioural and emotional work. Although my patients were often suffering with depression and anxiety, I did not see patients for whom this was the primary issue with weight and eating, or who had other significant psychological or psychiatric disorders, such as personality disorders and psychosis.
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What quickly became clear was the complexity of this patient group, many of whom had not received any support that gave consideration to their psychological needs and the origins of their eating behaviours before. As a team, we developed a multidisciplinary assessment which included Gad-71, PHQ-92 and Rosenberg self-esteem scale3 alongside dietary assessment, physical activity assessment and social information. In addition to this, my initial assessment would include a basic formulation of the presenting problem, discussion about the wants and needs of the individual patient, confidentiality and boundary setting. I was able to see patients for 45-minute sessions weekly, for up to 10 weeks. A high proportion of patients had suffered loss, grief, or had been victims of crime or abuse. Supervision and a strong multidisciplinary team were essential in maintaining our own health and perspective in this role. One of my first cases in this new role was a sharp indicator of things to come. A patient whose obesity began with all their male relatives being murdered in the home. As a result, this patient, as a child, was fed by the mums, aunties and grandparents of the deceased relatives, as a treat and comfort. This had never been disclosed before, so previous healthcare professionals had gone down the route of eat less, exercise more and ‘why are you not complying’? This had served to increase the sense of guilt and failure of this otherwise very successful professional and unsurprisingly led to little success with weight control. There were some common themes and, over time, I developed a way of
