What role do dietitians have in providing nutrition care for eating disorder treatment? An integrative review

Cocreating eating disorder education solutions: A design thinking approach to dietetics curricula in Australia

BACKGROUND

As the prevalence of eating disorders continues to increase, there is an urgent need to equip the emerging dietetics workforce to provide care to this growing population. The present study aimed to describe a five-step design thinking process that was applied to brainstorm ideas and develop and test solutions for consideration in the future.

METHODS

A pragmatic, five-step design thinking approach was used during a 1-day, in-person design thinking retreat. Purposive sampling was used to identify key stakeholders, including subject matter, learning and teaching, as well as lived experience experts, dietetics students and recent graduates. Reflexive thematic analysis was used to analyse brainstormed and design solution ideas.

RESULTS

Seventeen participants attended the design thinking retreat in April 2023. Four education prototypes were developed and tested by stakeholders including: (1) a change to accreditation requirements for dietetics curricula; (2) a multimodal learning package for penultimate year students; (3) embedding disordered eating and eating disorder content into existing curriculum and upskilling educators; and (4) codesigning an eating disorder module.

CONCLUSIONS

The design thinking retreat engaged a variety of stakeholders in curriculum design resulting in an array of prototype approaches that aimed to embed eating disorder content into university curricula. Further research is needed to test the prototypes and understand what impact this has on dietetics students' feelings of preparedness to provide care to people seeking this support.

Exploring culinary diversity to enhance Mediterranean diet adherence: A randomized controlled trial

We Investigated how promoting diverse, healthy food options affects long-term dietary choices. We hypothesized that encouraging exploration of nutritious plant-based foods would lead to lasting improvements in diet. Participants (N = 211) were randomly assigned into two groups for a 6-week intervention: The fixed menu group was given the same large menu every week, while the changing menu group received a new small menu each week. At the end of the intervention both groups were exposed to the same menu suggestions. Food diversity evaluation was based on weekly reports collected during the intervention. Self-reported adherence to Mediterranean diet components was assessed using the I-MEDAS screener. The proportion of plant-based foods in participants' diets was estimated using a 0-100% scale based on self-report. Both items were evaluated using online questionnaires given to participants at baseline, at the end of the intervention, as well as three and six months after the intervention concluded. Results mean(SD) demonstrated that participants in fixed menu group explored a significantly wider array of items 26.33(11.64) than those in the changing menus group [19.79(10.29), t(202) = 4.25, p < 0.001, Cohen's d = 0.60]. A repeated measures analysis of covariance rmANCOVA revealed that short-term increase in I-MEDAS and PBD score were noted in both groups; however, only participants with the fixed menu sustained this increase at months follow-up [diff = 1.50, t(132) = 4.50, p < 0.001 Our findings suggest that manipulating the rate of exposure to food suggestions may affect overall dietary variety. It seems that early presentation with options may increase overall dietary variety and may even support longer-term habits. This study contributes to developing effective interventions and highlights the challenge of promoting exploratory behavior in nutrition.

Management of eating disorders during pregnancy: A survey of Australian dietitians in clinical practice

BACKGROUND

Eating disorders (EDs) are estimated to affect 5.2%-7.5% of pregnant women, equating to 15,800-23,000 births in Australia annually. In pregnancy, an ED increases the risk of complications for both mother and child. Heightened motivation and increased utilisation of healthcare services during pregnancy present an opportunity to identify and commence ED treatment. Dietetic management of EDs differs from nutrition guidelines for pregnancy. This study aimed to assess current practice, confidence and training needs of dietitians to manage EDs in pregnancy.

METHODS

A cross-sectional survey of Australian dietitians with past year exposure to ED and/or antenatal fields was completed using Microsoft Forms between November 2022 and January 2023.

RESULTS

One hundred and seventeen responses were analysed. Confidence was less for assessment of a woman with an active ED in pregnancy than a pregnant woman with a history of an ED, pregnancy or an ED alone (p < 0.001). Greater than 5 years of experience as a dietitian, but without recent exposure to the patient population, was associated with increased confidence (p < 0.01). Almost half provided descriptions of treatments and interventions used to treat a pregnant woman with an ED, some of which conflict with ED or antenatal guidelines. Dietitians were more likely to weigh a person with an ED in pregnancy. Most respondents indicated further training (93%) and guidelines (98%) would be helpful.

CONCLUSION

This is the first investigation into the dietetic management of EDs in pregnancy, and it highlights a need for guidelines and training for dietitians.

'Through education, we can make change': A design thinking approach to entry-level dietetics education regarding eating disorders

AIMS

To co-create strategies and identify opportunities to integrate eating disorder content within dietetics curricula at one Australian university with stakeholders using a design thinking approach.

METHODS

A pragmatic mixed-methods, participatory design approach was used. An online survey explored the learning needs of dietetic students and recent graduates regarding eating disorders. Following the survey, a one-day design thinking retreat was held with stakeholders who were identified from the research team's professional networks. Eating disorder dietitians, learning experts, dietetic students, graduates, and those with lived experience were asked to identify strategies to enhance students' confidence and competence to provide care for people living with eating disorders. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using inductive coding and reflexive thematic analysis.

RESULTS

Sixty-four students (n = 55, 86%) and recent graduates (n = 9, 14%) completed the online survey (26% response). Seventeen stakeholders attended the retreat. Four themes were identified: (1) changing perceptions of eating disorder care from specialist to 'core business'; (2) desiring and advocating for a national change to dietetics curricula; (3) importance of lived experience at the centre of curriculum design and delivery; and (4) collaborating to co-design and deliver eating disorder content at university.

CONCLUSION

Raising awareness, upskilling students and educators, enhanced collaboration between universities and stakeholders, and the inclusion of lived experience were key to preparing students to provide care to people seeking support for eating disorders. Further research is needed to assess the impact these strategies have on dietetic students' confidence and competence.

The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives

BACKGROUND

Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue.

METHODOLOGY

Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN.

RESULTS

All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement.

CONCLUSIONS

This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

"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

Dietitians are included in eating disorder (ED) treatment teams for their expertise in nutrition. However, little is known about an individual's experience of dietetic intervention as part of their ED treatment and what they value as part of dietetic care. Therefore, the aim of this review was to synthesise the available qualitative literature to understand the role and value of a dietitian in ED treatment from the perspective of individuals with lived experience. Six databases and Google Scholar were searched and a thematic synthesis and meta-synthesis of fifteen studies were conducted. Four themes were constructed from the data: (1) "guidance and structure"-Provision of nutrition knowledge and skills; (2) "having all my bases covered"-Dietitians as part of a multidisciplinary team; (3) Challenges in nutritional treatment; and (4) "it was my treatment and my recovery"-Person-centred dietetic treatment. Across all identified themes was the cross-cutting theme of a shared treatment journey between the dietitian and the individual receiving treatment. These findings support dietitians having a role that is not limited only to the provision of nutrition treatment in ED care and illustrates the importance of dietitians engaging with clients by centring on the individual's needs and preferences. Further understanding helpful dietetic treatment components and identifying gaps in training is needed to develop these broader roles for dietetic care.

Exploring the eating disorder curricula of accredited university dietetic programs in Australia and New Zealand

BACKGROUND

Dietitians are viewed as integral members of the multidisciplinary treatment team for people with eating disorders (EDs). However, low levels of perceived confidence, competence, and willingness to practice in this clinical area, have been reported by dietitians and student dietitians. As the extent of ED-specific knowledge and skills-based training within tertiary accredited dietetic programs is currently unknown, this research aimed to: (1) obtain insights into the current ED-specific knowledge base and training content of dietetic curricula in both Australian and New Zealand universities; (2) understand the perspectives of course convenors regarding the role of dietitians in ED treatment and their employment opportunities; and (3) identify gaps and opportunities for improving university programs and the dietetic workforce.

METHODS

Course convenors (or their nominated representative) of Australian and New Zealand accredited dietetic programs were invited to participate in a semi-structured virtual interview. A purpose-built question guide was developed to explore the inclusion and/or integration of ED-specific content into the curricula, and the perspectives of course convenors toward the role of dietitians in the treatment of EDs, and their employment opportunities. The interviews were audio recorded, transcribed verbatim, and analysed qualitatively using inductive thematic analysis.

RESULTS

Thirteen participants who represented 14 universities and 19 individual accredited dietetic programs, were interviewed, with some participants representing more than one university. Three dominant themes emerged: (1) varying ED-specific content and training in dietetic programs; (2) unclear dietitian's role in the treatment of EDs, and (3) contrasting views regarding ED clinical practice and employment.

CONCLUSIONS

ED-specific content was embedded within all the dietetic programs investigated in this study. However, this content was generally limited to an introductory level, with notable variations found between the depth of content and the type of training provided. Risk-mitigation skill development, such as screening for EDs, and early identification of symptoms, also varied between programs. Therefore, it is recommended that ED-specific skill development and knowledge is enhanced within Australian and New Zealand university programs, to support effective, safe, and timely care for people with EDs. This research has implications for current and future university dietetic program development and the broader dietetic workforce.

Informing care through lived experiences: perspectives of consumers and carers regarding dietetic care for eating disorders in Australia

PURPOSE

Dietitians are important members of eating disorder treatment teams. Previous research indicates little is known about the experience of receiving nutrition care for eating disorders. This study aimed to explore the perspectives of consumers and carers regarding the care received from primary care dietitians for eating disorders.

METHODS

This study qualitatively explored the perceptions of individuals aged ≥ 15 years, who (i) identified as having an eating disorder or (ii) had cared for someone with an eating disorder, and had received care from a dietitian in a primary care setting. Thematic analysis was used to identify themes from interview transcripts. Synthesized member checking was utilized to assess whether the identified themes resonated with participants' experiences. Twenty-four individuals (21 consumers, 3 carers) participated in a semi-structured interview. Seventeen participants completed member checking and all supported the identified themes and subthemes.

RESULTS

Three themes emerged inductively from the data: (1) valuing a person-centered approach to dietetic care; (2) the therapeutic alliance is central to engaging in dietetic care; and (3) sharing the complex journey.

CONCLUSIONS

This study advances the understanding of the aspects of dietetic care perceived as most helpful by consumers and carers. These insights highlight the importance of person-centeredness, empathy, trust and collaboration within eating disorder care. The findings can be used by dietitians and health professionals to inform practice. Further research is needed to understand how dietitians can be supported to provide optimal nutrition care to people and families impacted by eating disorders.

LEVEL OF EVIDENCE

V. Qualitative study.