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Eating Disorders

Dietitians have a key role in the management of those suffering from eating disorders. We aim to promote Dietitians working within this field and provide guidance on best practice in this area .

 

As eating disorders comprise both psychological and physiological components, treatments should combine expertise in both with health professionals understanding the nutritional and physiological effects these disorders can have. Registered dietitians, registered with the Health and Care Professions Council, have an essential role within multidisciplinary teams and are involved in the assessment, treatment and monitoring of patients with anorexia nervosa, bulimia nervosa and binge eating disorder. Dietetic input should be offered to both inpatients and outpatients as an adjunct to other treatments.Dietitians are specialised in assessing nutritional requirements and are up to date in latest nutritional information, so can provide accurate and relevant information for patients including those with additional dietary requirements eg diabetes or food allergy.

 

As poor eating patterns and unhealthy views surrounding food are primarily symptoms of eating disorders, not the cause, dietary concerns can be addressed by a dietitian leaving other health professionals to deal with the underlying issues of the eating disorder. A dietitian can:

 

  • act as a specialist within a multi-disciplinary team
  • act as a consultant to other health professionals advising on nutritional aspects of care, appropriate literature to use and providing training as required
  • run nutrition education sessions for patients covering general topics with regards to nutrition and basic physiology
  • act as a co-therapist in individual treatments, and in therapy groups where nutrition is a major component eg bulimia nervosa or overeaters groups
  • have long-term individual contact with patients
  • review patient eating diaries
  • design and review nutrition plans for the patient
  • monitor weight and amend nutritional plans as appropriate
  • liaise with and support families and carers as required.

 

The role of the dietitian can be divided into 4 main areas:

 

Assessment

Dietetic assessment will vary depending on when the patient is being seen and what previous assessment has been carried out eg. dietetic outpatient assessment will be different from the assessment carried out by a dietitian working in a specialist inpatient unit.
Dietetic assessment includes:
  • current and previous dietary intake, eating habits and weight history
  • other eating disorder behaviour eg purging, use of laxatives and diuretics
  • history of weight reducing diets, including family history of dieting
  • current nutritional knowledge and dietary rules eg kcalorie counting, times of eating, ritualistic behaviours, food combining, avoidance of fats and fatty foods
  • activity level and exercise
  • motivation to change and patient’s aims of treatment
  • calculation of nutritional requirements for weight maintenance and weight gain (if required)
  • treatment plan

 
 

Nutrition Education

Nutrition education can seem unnecessary and be overlooked for patients with eating disorders as their knowledge and interest in nutrition can seem vast. However this is a major part of the problem. Patients are often overly concerned with small aspects of nutrition such as calorie counting, avoiding fats or carbohydrates. This can result in completely distorted views on food and nutrition, and a diet deficient in many nutrients. For some this has been a result of their eating disorder, but for others their poor diets predate this. A dietitian can help a patient review their current dietary Intake, question their dietary “rules” and provide more accurate information about nutrition and physiology to help them move towards a nutritionally adequate diet.

 

Recommendations

Ideally this involves the dietitian and patient working collaboratively to set realistic and achievable diet and weight goals. Goals for weight gain need to be slower for outpatient than for inpatient treatment. Recommendations should be backed up using results of nutritional analysis and calculations of nutritional requirements for weight maintenance and weight gain. A dietitian will only recommend the use of nasogastric feeding or use of supplementary drinks where this is absolutely necessary as a patient can quickly become reliant on these dietary props, preferring to use these rather than re-establishing a normal diet.

 

Support

Ultimately the role of a dietitian is to help patients learn to trust food again. When patients have followed restrictive or chaotic eating patterns for a period of time their beliefs about food and nutrition can become very distorted and rigid. Changing poor eating patterns is very difficult to do, even with very motivated patients. It inevitably means breaking numerous dietary “rules” and, as with other elements of treatment, involves risk and experimentation. A dietitian can be the best person to instil confidence in patients to make these changes.

 

Further information:
BDA position paper on Dietitians working with patients with eating disorders
BDA refeeding paper
refeeding guidelines
The Nutrition Intervention
http://www.daa.asn.au/files/DINER/Anorexia%20Nervosa_Final.pdf

 

Key skills and knowldge for Dietitians working in the Area of Eating Disorders (BDA position paper 2011)
  • Minimal postgraduate training in the area of mental health and eating disorders e.g. any of the following:
  1. BDA/MHG “Introduction to Mental Health” Course plus BDA /MHG “Introduction to Eating Disorders” course
  2. Leeds Metroploitian University/MHG  “Eating Disorders and Mental Health”  modules.
  • Band 6 or 7 with relevant post graduate experience of >1 year in the area of eating disorders, or closely clinically supervised by an experienced Dietitians working in the area of eating disorders for at least 1 year.
  • Behaviour change skills training for Dietitians levels 1 and 2 minimal.

Guidelines
American Dietetic Association: Nutrition Intervention in the treatment of Anorexia Nervosa, Bulimia Nervosa and Eating Disorders not otherwise specified 2001
Australian Dietetic Association Guidelines (2002) Treatment of Eating Disorders
British Dietetic Association Parenteral and Enteral Nutrition Group: guidelines on refeeding 2002. PEN handbook
British Dietetic Association. (2006). Briefing paper: A Consensus Statement for Dietitians Working in Eating Disorders
National Institute of Clinical Excellence (2004) Eating Disorders: full national guidelines www.nice.org.uk
NHS Quality Improvement Scotland. (2006) Eating Disorders in Scotland: Recommendations for Management and Treatmentwww.nhshealthquality.org
Royal Collage of Psychiatrists (2005) Guidelines for the Nutritional Management of Anorexia Nervosa

Books
Browell K, Fairburn C (Eds) Eating Disorders and Obesity. New York Guildford press. 2nd edition. 2002
Bloomfield Steve. Eating Dosorders: Helping your child recover
Cooper P, J. Bulimia Nervosa and Binge Eating: A guide to recovery
Fairburn Christopher Overcoming Binge Eating. – Guilford Press
Langley Jenny. Boys get Anorexia too. – Lucky Duck Publishing
Schmidt and Treasure . Getting bBetter Bit(e) by Bit(e)- A survival kit for sufferers of bulimia nervosa and binge eating disorders. Lawrence Erlbaum Associates
Treasure J. Anorexia Nervosa: a survival guide for families, friends and sufferers. – Psychology Press

Journals
International Journal of Eating Disorders
European Eating Disorders review
Eating Disorders: The journal of treatment and prevention
British Journal of Psychiatry
International Journal of Obesity

Web Sites
www.b-eat.co.uk. Eating Disorders Association
www.iop.kcl.ac.uk Royal college of psychiatry
hwww.cci.health.wa.gov.au/resources/minipax.cfm?mini_ID=19  info sheets & downloads
www.SNDRI.gcal.ac.uk Scottish Nutrition and Diet Resource Initiative (SNDRI) for up to date evidence based resources for Dietitians to use with Eating Disorder patients, developed by Dietitians with Psychology involvement.

The following link (http://www.iop.kcl.ac.uk/sites/edu/?id=73) gives links to key documents including:

Student Counsellor Guide to eating disorders
Download pdf

The SCOFF questionnaire
To aid early detection of eating disorders, developed by John Morgan at Leeds Partnerships NHS Foundation Trust.
Download pdf

Could this be an eating disorder?
A questionnaire to help establish whether there are sufficient reasons to be worried about a person’s state possibly being an eating disorder.
Download pdf

A Guide to the Medical Risk Assessment for Eating Disorders
Designed for use with outpatients and inpatients with eating disorders.
Download pdf

 

Protocol for management of hypophosphataemia as part of the refeeding syndrome
To be read in conjunction with A Guide to the Medical Risk Assessment for Eating Disorders and Guidelines for assisted feeding in patients displaying extreme dietary restraint.
Download pdf

Post discharge care and relapse prevention plan
Download pdf

Maudsley Body Mass Index Table
Download pdf

Maudsley Nutritional Health Over Time Chart
Download pdf

A GP’s Guide to Eating Disorders
Download pdf

Medical complications of anorexia nervosa
Download pdf

Motivational Interviewing
Download pdf

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