RESEARCH
DIETITIANS IN EATING DISORDERS: A PILOT STUDY Kerry McLeod RD Member of the BDA Specialist Mental Health Group & Beat Ambassador Kerry currently works for Child and Adolescent Mental Health Services in Aneurin Bevan University Health Board, where she is responsible for the dietetic management of young people with eating disorders attending the Intensive Treatment Programme.
Dr Myra Mackenzie Lecturer in Nutrition and Dietetics, Robert Gordon University Myra has been a lecturer in the School of Pharmacy and Life Sciences at RGU since 2009. Her research interests include the role of the dietitian in promoting nutritional care in vulnerable groups, food security and community engagement.
Eating disorders (EDs) are serious mental disorders with high levels of physical and psychological comorbidity, disability and mortality.1 Dietitians possess a range of skills and knowledge, including nutrition, sociology, physiology, psychology and behaviour change. They are involved in the assessment, treatment and monitoring of clients with EDs,2 within multidisciplinary teams, helping patients to improve their relationship with food, as well as educating other clinicians.2 Publications on dietetic practice in the area of EDs are often descriptions of practice, excluding the perspectives of service users.3 Qualitative studies in EDs demonstrate the importance of individualised treatment interventions and the therapeutic relationship in recovery.4 We report here a pilot study that evaluates the dietetic treatment experiences of individuals with history of EDs. We invited a group of participants aged ≥18 years old, who had received dietetic treatment for an ED but were no longer receiving ED treatment, to participate in an online questionnaireRESULTS
All participants were female and the majority <40 years old (n 12). Most participants had anorexia nervosa (n 12) followed by Eating Disorder Not Otherwise Specified (n 1). Participants’ views of dietetic input Most participants reported that their views on dietetic input changed throughout treatment: “At the start, naturally, I disliked my dietitian - my anorexia told me she just wanted to make me fat.” “At the beginning of treatment I didn’t see the need for dietetic input, but towards the end I could see the benefits.” They felt that the dietitian had a good understanding of their condition, but lack of experience in EDs could present difficulties:
led survey. The study was advertised via the Beat website, research newsletter and social media. Respondents (n 18) were sent information sheets and consent forms via email; 13 study participants remained. Ethical approval was given by The Robert Gordon University School of Pharmacy and Life Sciences Research Ethics Committee and approval for the study was granted by the Beat Research Officer. Responses were examined and a thematic analysis carried out. An essentialist approach was taken (i.e. the language used reflects meaning and experience).5 “One of the locums I saw said some really triggering and unhelpful things due to not really knowing me or misinterpreting things I said. They also seemed to have some very stereotyped views about people with EDs which came across as patronising and dismissive - I don’t think they had experience of working in this area.” See the person, not the disorder “It felt like she’d seen the label of anorexia and tried to help treat that. I didn’t feel like she listened to me or treated me as an individual.” “Concerns [were] frequently dismissed as symptomatic of the eating disorder, as though that was a reason to disregard them, rather than address them.” www.NHDmag.com March 2018 - Issue 132
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RESEARCH Participants frequently commented on how they felt when concerns were not dealt with appropriately: “I was very open about how I felt, my thoughts and feelings, however, I do not think these were challenged in an appropriate way, and ended up making me feel worse about myself…I felt my irrational ideas were shrugged off as something I could just ‘get over’ rather than addressed. At times I felt ignored.” Some participants did not feel that their food rules/rituals were explored or challenged appropriately. One participant explained the necessity of challenging ‘feared foods’ and the potential consequences of not doing so: “I often went several weeks at a time without any input…this impacted on my ability to sustain or make changes…mainly due to feeling unable to challenge my fears/thoughts well enough myself.” “Working through a feared food list, I felt the changes I was expected to make were not achievable in the short time frame she had set… more time should have been taken.” Trust is important Several participants commented on the importance of trust; one participant stated that it was ‘crucial’ in recovery: “[We] built up a lot of trust over the years… it took a lot of repetition for me to realise that a lot of the things they were telling me DID make sense, or apply to me - and to be able to use their support to make lasting changes.” Collaboration vs battles Participants favoured a collaborative approach to treatment: “She let me pick foods I liked and worked with me to make meal plans that I felt I could manage, actually enjoy to an extent.” ‘Controlling’ dietitians led some to rebel: “At times when I didn’t feel listened to, this would result in me completely going against what she was advising me to do. I think there needs to be a mutual respect with the dietitian and the patient. If there’s not, then I don’t think it will benefit the patient at all.” “Arbitrary rules or requirements and a lack of flexibility led me to want to reject everything the 12
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dietitian had to offer…[The patient and dietitian] are frequently pitted against one another rather than working collaboratively towards the same goals. A refusal to compromise and empathise led to increased resistance.” In contrast, when asked what was most helpful during the intervention, one of the participants reported: “Getting the control taken away I guess. I hated it but I needed it.” Implementing advice Several participants reported that they already knew much of the information, but experienced difficulty in implementing it: “A lot of the info I did know already, about food groups and energy balance. I just couldn’t put it into practice and wasn’t given any help with this.” “I knew what I needed to do, so didn’t need information/instruction, but support in implementation.” Participants recognised the importance of current knowledge: “It didn’t appear to be rooted in evidence-based practice, or make use of the science that points towards ways in which diet could have been used to alleviate other symptoms/side effects associated with my ED…They don’t want to offer hard or factual dietary advice in fear of exacerbating the patient’s fears or obsessions surrounding food… dietary education, empowerment and knowledgemobilisation needs to take place when working with ED patients.” Several commented on the importance of language during nutritional education: “My outpatient dietitian was an amazing role model in the way she talked about food…she’d talk more in terms of nutrients and protein rather than calories and fat, which was amazing. [My inpatient dietitian] made it very much about calories and fat which made it even more difficult.” Similarly, placing a ‘focus on the flavours and nutritional values’ was more helpful than focusing on calories. Participants did not value interventions focused solely on weight restoration: “There seemed to be a heavy emphasis on getting calories in…I can remember some discussion
about low volume high calorie foods. Everything seemed like a trick to get me to eat, rather than a means of addressing my negative eating rituals.” “It would have been great to have the continuity of someone supporting me…rather than simply reviewing my calorie intake and weight progress.” DISCUSSION
Although this was a small study and participants were self-selected, interesting themes were identified which have implications for dietetic management. Responses reflected the importance of core human values: empathy, being treated as an individual and being listened to. It was unhelpful when staff conveyed assumptions regarding how people with anorexia nervosa behave or think.6,7 Many participants highlighted the importance of establishing trust, but emphasised that this takes time. Anorexia nervosa can often be considered as part of a sufferer’s identity which can make the decision to accept treatment more difficult.8,9 The importance of a collaborative approach to treatment which encourages responsibility and autonomy, was highlighted by participants. It has been reported that rigid treatment programmes may result in patients rebelling,10 a phenomenon that resonated throughout participants’ responses in the present study. The phenomenon known as ‘battling’ is described by Palmer,11 with the internal conflict developing into an external
conflict with those who are imposing change. In such situations, the ED thrives as the individual tries to maintain a sense of autonomy. Ways of involving people in their own care include practices such as plotting one’s own weight chart, being given clear factual information, establishing one’s own goals, and having staff listen to problems in a clientled manner. Clinicians who focus on food and weight rather than feelings and underlying anxieties were deemed as unhelpful; dietitians should encourage a ‘healthy state rather than a healthy weight’.12 Over emphasis on weight restoration may result in patients gaining weight to get out of hospital but quickly relapsing.7 The language used during dietetic consultations is important and it is unhelpful to discuss food in terms of ‘calories’ and ‘fat’ rather than ‘nutrients’, ‘protein’ and ‘flavours’. Dietitians should provide support with practical and social eating skills, such as shopping, cooking and eating with others.13 Most participants in the current study reported that guidance on these key skills was not provided during treatment. ED patients relate best to an individualised, collaborative approach that addresses the physiological and psychological elements of the disorder in parallel. Further research could explore the relationships within the dietitianpatient interaction in order to incorporate the most effective strategies for establishing a positive therapeutic alliance with these clients.
References 1 Royal College of Psychiatrists (2012). Eating disorders in the UK: service distribution, service development and training. London: Royal College of Psychiatrists 2 Cockfield A and Philpot U (2009). Symposium 8: Feeding size 0: the challenges of anorexia nervosa. Managing anorexia from a dietitian’s perspective. Proceedings of the Nutrition Society, 68, 281-288. DOI: 10.1017/S0029665109001281 3 Hart S, Russell J and Abraham S (2011). Nutrition and dietetic practice in eating disorder management. Journal of Human Nutrition and Dietetics, 24, 144153. DOI: 10.1111/j.1365-277X.2010.01140.x 4 Federici A and Kaplan AS (2008). The patient’s account of relapse and recovery in anorexia nervosa: a qualitative study. European Eating Disorders Review, 16, 1-10. DOI: 10.1002/erv.813 5 Widdicombe S and Wooffitt R (1995). The language of youth subcultures: social identity in action. Harvester Wheatsheaf 6 Offord A, Turner H and Cooper M (2006). Adolescent inpatient treatment for anorexia nervosa: a qualitative study exploring young adults’ retrospective views of treatment and discharge. European Eating Disorders Review, 14, 377-387. DOI: 10.1002/erv.687 7 Tierney S (2008). The individual within a condition: a qualitative study of young people’s reflections on being treated for anorexia nervosa. Journal of the American Psychiatric Nurses Association, 13, 368-375. DOI: 10.1177/1078390307309215 8 Bezance J and Holliday J (2013). Adolescents with anorexia nervosa have their say: a review of qualitative studies on treatment and recovery from anorexia nervosa. European Eating Disorders Review, 21, 352-360. DOI: 10.1002/erv.2239 9 Schmidt U (2015). Anorexia nervosa - in 100 words. The British Journal of Psychiatry, 207, 4 10 Treasure J, Crane A, McKnight R, Buchanan E and Wolfe M (2011). First do no harm: iatrogenic maintaining factors in anorexia nervosa. European Eating Disorders Review, 19, 296-302. DOI: 10.1002/erv.1056 11 Palmer B (2014). Helping people with eating disorders: a clinical guide to assessment and treatment (2nd ed). Chichester, UK: Wiley-Blackwell 12 Mittnacht AM and Bulik CM (2015). Best nutrition counselling practices for the treatment of anorexia nervosa: a Delphi study. International Journal of Eating Disorders, 48, 111-122. DOI: 10.1002/eat.22319 13 Ashley M and Crino N (2010). A novel approach to treating eating disorders in a day-hospital treatment program. Nutrition and Dietetics, 67, 155-159. DOI: 10.1111/j.1747-0080.2010.01448.x
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