Dietitians can add value to your eating disorder treatment team

A collaborative, multidisciplinary team is key to better health outcomes.

Introduction

If you’ve sought treatment in relation to an eating disorder, you might be wondering: why is it important that I include a dietitian on my treating team? Isn’t it enough to see a general practitioner and psychologist? What can a dietitian provide that I’m not already receiving?

These are valid questions, and ones that both laypeople and researchers are currently asking. Given their importance, I would like to delve into them and endeavor to offer some clarity.

Dietitians have long been involved in eating disorder treatment teams

Dietitians have long been involved in treatment teams for people with eating disorders, whether in inpatient and outpatient settings. In 2019, the Australian Government recognised the significant role played by dietitians in eating disorder treatment by including them in the Medicare Eating Disorder Treatment Plan (EDTP)^4,6. Indeed, you can access up to 20 sessions with a dietitian under the EDTP for a 12-month period.

What do the clinical guidelines recommend?

In clinical practice guidelines, such as those produced by the RANZCP, it is recommended that a collaborative approach is taken to ensure the medical, nutritional, and psychological aspects of treatment are met – something that includes dietetics expertise. Dietitians Australia also affirms the significant contribution dietitians make to the treatment team and provides details of a dietitian’s role and scope of practice. And now we have the ANZAED Eating Disorder credentialing system, which sets out a pathway for clinicians (including dietitians), to be adequately trained in order to provide safe and effective eating disorder care. It provides a service to the community in helping people find and connect with credentialed treatment providers to get the help they need.

The inclusion of dietitians in best-practice guidelines attests to their importance, as acknowledged by some of the country’s leading health institutions. Yet despite significant evidence supporting a dietitian’s role in a person’s treating team, other clinicians and health specialists may not always appreciate the distinctive contribution a qualified dietitian can make. Nor has a dietitian’s place in a person’s treatment program been well defined by manualised treatment models like CBT-E, FBT or MANTRA (Manualised Anorexia Treatment for Adults)^2,6. This is perhaps where some confusion lies for referring practitioners and individuals seeking treatment.

It’s important that we return to first principles and examine some of the fundamentals of dietetics practice to see just how crucial a skilled dietitian can be. Understanding the nature of an eating disorder is therefore a good place to begin.

What is an eating disorder?

The term “eating disorder” can sometimes seem unclear. Clarification is therefore necessary, particularly as an accurate understanding can help us discern the importance of having a collaborative treatment team – including, of course, a dietitian.

Eating disorders constitute a type of psychiatric condition characterised by both physiological and psychological consequences^1,8. Disturbances in eating behaviours as well as attitudes to food, nutrition, exercise, weight, and shape are common threads.

Given this complexity – and in particular, the mutually influential relationship between a person’s psychology and their physiology – one can begin to discern the benefits of including domain-specific health professionals in a patient’s treating team^1,4,5,7. Indeed, the literature is clear: although eating disorders are considered psychiatric conditions, they have significant and palpable physiological consequences requiring nutritional management¹.

What does the dietitian’s role include?

Although it may not be well defined in many treatment models, research exists that goes some way to describing a dietitian’s role. Heafala 2021 states “The role of dietitians [has been] described as providing patient-centred care that includes the assessment, planning, treatment and management of nutritional requirements for medical stabilisation and recovery, which are tailored to the patient’s state of change and level of motivation.”

In their role on a multidisciplinary team, dietitians are most qualified⁵ to provide nutrition education concerning a broad range of topics, including but not limited to:

• weight changes
• body image
• metabolism
• normalising eating patterns
• identifying and challenging misinformation and beliefs about food and nutrition
• the consequences of malnutrition
• gut health
• meal support strategies^5,6,7
• diet culture
• Intuitive eating skills
• Mindful eating

In sum, dietitians provide helps individuals foster a healthy relationship with food and their body.⁴ So let’s explore more of what this means.

Providing a road map for nutrition recovery in eating disorder treatment

Now the process of change and healing one’s relationship with food can feel daunting, even overwhelming. It is very common for people seeking help to say plaintively, “I want recovery, but what does it actually mean or look like and how do I get there?” They may even state, “I just don’t know what ‘normal’ or ‘healthy’ eating is anymore.” These are valid concerns, and ones that need to be explored well, as they support the process of change.

Part of my role as a dietitian to help you chart a tailored path forward on your journey towards a far healthier relationship with food. Of course, recovery isn’t a linear process; in fact, set-backs are normal, and can even provide opportunities for you to practice compassion and build self-understanding. What’s more, my training enables me to use those moments to probe that understanding with you, thereby unearthing the beliefs and assumptions that can sustain a person’s distorted relationship with food.

The RAVES^TM eating model is a good example of the kind of distinctive treatment framework a dietitian may deploy. Developed by dietitian Shane Jeffery, the model provides a three-phase structure for nutrition rehabilitation. Indeed, this supports people in developing a healthy relationship with food, and is discussed and applied in a individualised way.

The first phase focuses on a regular and adequate intake of food. Following this, Phase 2 concentrates on expanding the range of foods one is comfortable eating; here, individuals are supported to eat in a more flexible and spontaneous way, which is designed to reduce discomfort and build confidence in social settings. The third phase, meanwhile, helps the individual develop intuitive eating skills that are relevant and tailored.

Practical steps towards recovery – food experiences

Healing your relationship with food and your body also encompasses a suite of practical elements and techniques. These might include:

• identifying and challenging eating disorder beliefs about food and nutrition
• learning to unhook yourself from eating disorder beliefs
• tuning into your body and its signals
• learning to experience food without judgement
• meal planning and cooking skills
• meal support strategies
• developing safety with social eating

Dietitians can offer a unique perspective in this aspect of treatment. For example, they can plan and implement collaborative food experiences, such as eating together in session. This allows individuals to enjoy support as they challenge food rules and fears. Such experiences provide opportunities for people to connect with their bodies and food mindfully within a comfortable setting. Indeed, food experiences are a rich time of learning and skill-building. In particular, they allow people to:

• identify and challenge eating disorder thoughts
• practice mindful eating
• build a sense of safety with food
• eat a wider range of foods
• change one’s relationship with foods that trigger bingeing
• boost the satisfaction factor
• enjoy a less restrictive and anxious approach to food and meals
• move towards a place of joy in nourishing one’s body

Providing medical nutrition therapy

Finally, as I mentioned earlier, several nutrition and medical issues are associated with eating disorders.¹ A Credentialed Eating Disorder Dietitian (CEDC_C) can provide medical nutrition therapy for these health ramifications.¹ This is where their unique skills, training, and expertise can come to the fore.

Why, then, is it beneficial to include a dietitian on your treatment team?

A multidisciplinary approach to eating disorder care is what evidence-based practice guidelines recommend.^5,8 Indeed, the World Health Organisation (WHO) has developed a Framework for Action on Interprofessional Education and Collaborative Practice (ICP), which has been endorsed worldwide.^2,3 The framework has been crafted for multiple health professionals involved in same-patient care, and provides guidelines designed to foster integrated, cohesive treatment. Bray, et. al. states that in the mental health sector, the ICP is associated with improved health outcomes, reduced treatment dropout rates and increased patient satisfaction with services.²

Dietitians are recognised as highly qualified health professionals with a distinct therapeutic perspective. They are trained in a variety of domains that may not be represented by other members of a person’s treating team. These may include human physiology, biochemistry, pathology and eating behaviour.⁶ Such broad, inter-disciplinary training positions dietitians to be of great value as they provide nutrition counselling and Medical Nutrition Therapy.^2,6,7

Nutrition content best delivered by a trained dietitian

A recent review of eating disorder treatment manuals identified that 91% of them contained some degree of nutrition-focused content.⁶ However, an analysis of treatment manuals for anorexia nervosa, showed that 60% contained nutrition content that was not substantiated by current evidence.^2,6 It is common for such information to be provided by a mental health professional rather than a dietitian, as the former is frequently responsible for treating dietary restraint. Nevertheless, a dietitian’s training and domain-specific expertise mean they are best placed to provide accurate nutrition education and address nutrition misinformation.^2,5

In summary, it is clear that a multidisciplinary approach ensures best outcomes for patients, and that dietitians can value add to the treatment being offered. To ensure optimal recovery from an eating disorder, the medical, nutritional, physiological, and psychological aspects of a person’s treatment require integrated and concurrent attention.⁶ A dietitian’s training sensitises them to the overlapping relationships between these domains, while offering distinct nutrition-related advice.

If you still have questions about a dietitian’s role in the treatment of eating disorders, please feel free to reach out to me with your questions.

References

1. American Dietetic Association (ADA) Report. Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS). Journal of the American Dietetic Association. (2001) 101:7.
2. Bray et al. Collaborative dietetic and psychological care in Interprofessional Enhanced Cognitive Behavioural Therapy for adults with Anorexia Nervosa: a novel treatment approach. Journal of Eating Disorders. 2023: 11(31).
3. Gilbert J.G., Yan J., Hoffman S.J. A WHO report: framework for action on interprofessional education and collaborative practice. Journal of Allied Health. (2010): 39 (Supp 1):196-197.
4. Heafala, A and Mitchell, L. and Ball, L. Informing care through lived experiences: perspectives of consumers and carers regarding dietetic care for eating disorders in Australia. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Ovesity. 2022: 27: 3449-3456.
5. Heafala, A et al. What role do dietitians have in providing nutrition care for eating disorders treatment? An integrative review. Journal of Human Nutrition and Dietetics. 2021: 34:724-735.
6. Jeffery, S. and Heruc, G. Balancing nutrition management and the role of dietitians in eating disorder treatment. Journal of Eating Disorders. 2020: 8(64).
7. Roberts, E. et. al. Scoping survey of dietetic resourcing for eating disorders: why is the dietitian’s role marginalised in community eating disorders? General Psychiatry. (2024) 37:e101604
8. Yang, Y. et. al. Beyond Refeeding: The Effect of Including a Dietitian in Eating Disorder Treatment. A Systematic Review. Journal of Nutrients. (2021) 13:4490.
9. Yang, Y. et. al. Review “I Need Someone to Help Me Build Up My Strength”: A Meta-Synthesis of Lived Experience Perspectives on the Role and Value of a Dietitian in Eating Disorder Treatment. Behavioural Sciences.(2023) 13, 944