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Advances in the dietetic management of eating disorders

Author/s
Cliona Brennan, Sarah J. Fuller, Lisa Waldron, Namrata Dhopatkar
Citation
Focus Issue 6: Eating disorders
CEPiP.2024.1.249-256
Abstract

Eating disorders (EDs) are highly complex illnesses, compromising both physical and mental health. Dietetic management of EDs has advanced over time, in line with research and clinical practice in the field. Progress in dietetic practice relates to the core domains of refeeding syndrome management, nutritional rehabilitation and nutritional psychoeducation. Advances in these domains are discussed in this narrative review. Future trends in health and disease that may shape further advances in the dietetic management of EDs are highlighted and their potential impact on nutritional interventions hypothesised. This review highlights the integral role of dietitians as part of an eating disorder multidisciplinary team. The skills and knowledge of the dietetic profession continues to advance and evolve in line with the expanding ED evidence base, supporting evidence-based dietetic practice and the ongoing development of nutritional strategies in this area.

Cite as: Cutting Edge Psychiatry in Practice 2025, 6(1):249-256; https://doi.org/10.65031/holi5748

References

  1. Judd P. The role of the dietician. Encyclopedia of Human Nutrition (2005) p. 32-8.            
  2. Morgan K, Reidlinger DP, Sargeant S, Crane L, Campbell KL. Challenges in preparing the dietetics workforce of the future: an exploration of dietetics educators' experiences. Nutrition and Dietetics. 2019;76(4):382-91. https://doi.org/10.1111/1747-0080.12438
  3. Greenlees NT, Pit SW, Ross LJ, McCormack JJ, Mitchell LJ, Williams LT. A novel blended placement model improves dietitian students' workreadiness and wellbeing and has a positive impact on rural communities: a qualitative study. BMC Medical Education. 2021;21(1):1-12. https://doi.org/10.1186/s12909-021-02756-y
  4. Micali N, Hagberg KW, Petersen I, Treasure JL. The incidence of eating disorders in the UK in 2000 - 2009: findings from the General Practice Research Database. BMJ Open. 2013;3(5):e002646. https://doi.org/10.1136/bmjopen-2013-002646
  5. Hay P. Current approach to eating disorders: a clinical update. Internal Medicine Journal. 2020;50(1):24-9.        
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Arlington, VA. American Psychiatric Association (2013). https://doi.org/10.1007/springerreference_179660
  7. Royal College of Psychiatrists. CR 233: Medical emergencies in eating disorders (MEED). Guidance on recognition and management 2022. Accessed 23 November 2023. Available from: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/collegereports/college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf?sfvrsn=2d327483_63. https://doi.org/10.1016/j.clnesp.2023.12.076
  8. National Institute for Health and Care Excellence (NICE). Eating disorders: recognition and treatment. NICE guideline [NG69] 2017. Updated 16 December 2020. Accessed 6 October 2023. Available from: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#identification-and-assessment. https://doi.org/10.24292/01.mf.0120.14
  9. Neale J, Hudson LD. Anorexia nervosa in adolescents. British Journal of Hospital Medicine. 2020;81(6):1-8.        
  10. Jeffrey S, Heruc G. Balancing nutrition management and the role of dietitians in eating disorder treatment. Journal of Eating Disorders. 2020;8(1):64. https://doi.org/10.1186/s40337-020-00344-x
  11. Hart S, Russell J, Abraham S. Nutrition and dietetic practice in eating disorder management. Journal of Human Nutrition and Dietetics. 2011;24(2):144-53. https://doi.org/10.1111/j.1365-277x.2010.01140.x
  12. McMaster CM, Wade T, Basten C, Franklin J, Ross J, Hart S. Rationale and development of a manualised dietetic intervention for adults undergoing psychological treatment for an eating disorder. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2021;26:1467-81. https://doi.org/10.1007/s40519-020-00955-y
  13. Yang Y, Conti J, McMaster C, Hay P. Beyond Refeeding: the effect of including a dietitian in eating disorder treatment. A systematic review. Nutrients. 2021;13(12):4490. https://doi.org/10.3390/nu13124490
  14. McMaster CM, Wade T, Franklin J, Hart S. Development of consensus‐based guidelines for outpatient dietetic treatment of eating disorders: a Delphi study. International Journal of Eating Disorders. 2020;53(9):1480-95. https://doi.org/10.1002/eat.23330
  15. Hart S, Marnane C, McMaster C, Thomas A. Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder. Journal of Eating Disorders. 2018;6(1):1-11. https://doi.org/10.1186/s40337-018-0192-4
  16. Heafala A, Ball L, Rayner J, Mitchell LJ. What role do dietitians have in providing nutrition care for eating disorder treatment? An integrative review. Journal of Human Nutrition and Dietetics. 2021;34(4):724-35. https://doi.org/10.1111/jhn.12927/v2/response1
  17. Kohn MR, Madden S, Clarke SD. Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Current Opinion in Pediatrics. 2011;23(4):390-4. https://doi.org/10.1097/mop.0b013e3283487591
  18. Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, et al. A systematic review of approaches to refeeding in patients with anorexia nervosa. International Journal of Eating Disorders. 2016;49(3):293-310. https://doi.org/10.1002/eat.22482
  19. Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, Garber AK, et al. Update on the medical management of eating disorders in adolescents. Journal of Adolescent Health. 2015;56(4):370-5. https://doi.org/10.1016/j.jadohealth.2014.11.020
  20. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008;336(7659):1495-8. https://doi.org/10.1136/bmj.a301
  21. Katzman DK. Refeeding hospitalized adolescents with anorexia nervosa: is "start low, advance slow" urban legend or evidence based? Journal of Adolescent Health. 2012;50(1):1-2. https://doi.org/10.1016/j.jadohealth.2011.10.003
  22. Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. Journal of Adolescent Health. 1998;22(3):239-43. https://doi.org/10.1016/s1054-139x(97)00163-8
  23. Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, et al. Refeeding and weight restoration outcomes in anorexia nervosa: challenging current guidelines. International Journal of Eating Disorders. 2015;48(7):866-73. https://doi.org/10.1002/eat.22390
  24. Powers PS, Cloak NL. Failure to feed patients with anorexia nervosa and other perils and perplexities in the medical care of eating disorder patients. Eating Disorders. 2013;21(1):81-9. https://doi.org/10.1080/10640266.2013.741994
  25. Le Grange D, Accurso EC, Lock J, Agras S, Bryson SW. Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa. International Journal of Eating Disorders. 2014;47(2):124-9. https://doi.org/10.1002/eat.22221
  26. O'Connor G, Nicholls D, Hudson L, Singhal A. Refeeding low weight hospitalized adolescents with anorexia nervosa: a multicenter randomized controlled trial. Nutrition in Clinical Practice. 2016;31(5):681-9. https://doi.org/10.1177/0884533615627267
  27. Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, et al. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with anorexia nervosa: a multicenter randomized clinical trial. JAMA Pediatrics. 2021;175(1):19-27. https://doi.org/10.1001/jamapediatrics.2020.3359
  28. Royal College of Psychiatrists. Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia Nervosa London (2012). Accessed 23 November 2023. Available from: http://www.rcpsych.ac.uk/publications/collegereports.aspx.          
  29. Eisler I, Simic M, Blessitt E, Dodge L, Team M. Maudsley Service Manual for Child and Adolescent Eating Disorders (2016). 
  30. Li Z, Halls D, Byford S, Tchanturia K. Autistic characteristics in eating disorders: Treatment adaptations and impact on clinical outcomes. European Eating Disorders Review. 2022;30(5):671-90. https://doi.org/10.1002/erv.2875
  31. Bryant‐Waugh R, Micali N, Cooke L, Lawson EA, Eddy KT, Thomas JJ. Development of the Pica, ARFID, and Rumination Disorder Interview, a multi‐informant, semi‐structured interview of feeding disorders across the lifespan: a pilot study for ages 10–22. International Journal of Eating Disorders. 2019;52(4):378-87. https://doi.org/10.1002/eat.22958
  32. Coglan L, Otasowie J. Avoidant/restrictive food intake disorder: what do we know so far? BJPsych Advances. 2019;25(2):90-8. https://doi.org/10.1192/bja.2018.48
  33. Kambanis PE, Thomas JJ. Assessment and treatment of avoidant/restrictive food intake disorder. Current Psychiatry Reports. 2023;25(2):53-64. https://doi.org/10.1007/s11920-022-01404-6
  34. Fisher M, Zimmerman J, Bucher C, Yadlosky L. ARFID at 10 years: a review of medical, nutritional and psychological evaluation and management. Current Gastroenterology Reports. 2023:1-9. https://doi.org/10.1007/s11894-023-00900-w
  35. Norris ML, Spettigue W, Hammond NG, Katzman DK, Zucker N, Yelle K, et al. Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder. International Journal of Eating Disorders. 2018;51(2):170-3. https://doi.org/10.1002/eat.22814
  36. Feillet F, Bocquet A, Briend A, Chouraqui J-P, Darmaun D, Frelut M-L, et al. Nutritional risks of ARFID (avoidant restrictive food intake disorders) and related behavior. Archives de P.diatrie. 2019;26(7):437-41. https://doi.org/10.1016/j.arcped.2019.08.005
  37. Mammel KA, Ornstein RM. Avoidant/restrictive food intake disorder: a new eating disorder diagnosis in the Diagnostic and Statistical Manual 5. Current Opinion in Pediatrics. 2017;29(4):407-13. https://doi.org/10.1097/mop.0000000000000507
  38. Archibald T, Bryant‐Waugh R. Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions. JCPP Advances. 2023:e12160. https://doi.org/10.1002/jcv2.12160
  39. Fisher M, Gonzalez M, Malizio J. Eating disorders in adolescents: how does the DSM-5 change the diagnosis? International Journal of Adolescent Medicine and Health. 2015;27(4):437-41. https://doi.org/10.1515/ijamh-2014-0059
  40. Brennan C, Illingworth S, Cini E, Bhakta D. Medical instability in typical and atypical adolescent anorexia nervosa: a systematic review and meta-analysis. Journal of Eating Disorders. 2023;11(1):1-13. https://doi.org/10.1186/s40337-023-00779-y
  41. Walsh BT, Hagan KE, Lockwood C. A systematic review comparing atypical anorexia nervosa and anorexia nervosa. International Journal of Eating Disorders. 2023;56(4):798-820. https://doi.org/10.1002/eat.23856
  42. Sawyer SM, Whitelaw M, Le Grange D, Yeo M, Hughes EK. Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics. 2016;137(4):e20154080. https://doi.org/10.1542/peds.2015-4080
  43. Whitelaw M, Lee KJ, Gilbertson H, Sawyer SM. Predictors of complications in anorexia nervosa and atypical anorexia nervosa: degree of underweight or extent and recency of weight loss? Journal of Adolescent Health. 2018;63(6):717-23. https://doi.org/10.1016/j.jadohealth.2018.08.019
  44. Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, et al. Weight loss and illness severity in adolescents with atypical anorexia nervosa. Pediatrics. 2019;144(6):e20192339. https://doi.org/10.1542/peds.2019-2339
  45. Moskowitz L, Weiselberg E. Anorexia nervosa/atypical anorexia nervosa. Current Problems in Pediatric and Adolescent Health Care. 2017;47(4):70-84. https://doi.org/10.1016/j.cppeds.2017.02.003
  46. Vo M, Golden N. Medical complications and management of atypical anorexia nervosa. Journal of Eating Disorders. 2022;10(1):196. https://doi.org/10.1186/s40337-022-00720-9
  47. Brennan C, Baudinet J, Simic M, Eisler I. 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. Nutrients. 2024;16(5):670. https://doi.org/10.3390/nu16050670
  48. Matthews A, Kramer RA, Mitan L. Eating disorder severity and psychological morbidity in adolescents with anorexia nervosa or atypical anorexia nervosa and premorbid overweight/obesity. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2022:1-10. https://doi.org/10.1007/s40519-021-01168-7
  49. Eiring K, Wiig Hage T, Reas DL. Exploring the experience of being viewed as "not sick enough": a qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa. Journal of Eating Disorders. 2021;9:1-10. https://doi.org/10.1186/s40337-021-00495-5
  50. Freizinger M, Recto M, Jhe G, Lin J. Atypical anorexia in youth: cautiously bridging the treatment gap. Children. 2022;9(6):837. https://doi.org/10.3390/children9060837
  51. Kinnaird E, Norton C, Tchanturia K. Clinicians' views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study. BMC Psychiatry. 2017;17(1):1-8. https://doi.org/10.1186/s12888-017-1455-3
  52. Leppanen J, Sedgewick F, Halls D, Tchanturia K. Autism and anorexia nervosa: longitudinal prediction of eating disorder outcomes. Frontiers in Psychiatry. 2022;13:985867. https://doi.org/10.31234/osf.io/rvxdk
  53. Cobiac LJ, Scarborough P, Kaur A, Rayner M. The Eatwell guide: modelling the health implications of incorporating new sugar and fibre guidelines. PLoS One. 2016;11(12):e0167859. https://doi.org/10.1371/journal.pone.0167859
  54. O'Connor G, Oliver A, Corbett J, Fuller S. Developing clinical guidelines for dietitians treating young people with anorexia nervosa-family focused approach working alongside family therapists. Ann Nutr Disord Ther. 2019;6(1):1056.         
  55. Fuller SJ, Brown A, Rowley J, Elliott-Archer J. Veganism and eating disorders: assessment and management considerations. BJPsych Bulletin. 2022;46(2):116-20. https://doi.org/10.1192/bjb.2021.37
  56. Zuromski KL, Witte TK, Smith AR, Goodwin N, Bodell LP, Bartlett M, et al. Increased prevalence of vegetarianism among women with eating pathology. Eating Behaviors. 2015;19:24-7. https://doi.org/10.1016/j.eatbeh.2015.06.017
  57. Seitz J, Trinh S, Herpertz-Dahlmann B. The microbiome and eating disorders. Psychiatric Clinics. 2019;42(1):93-103. https://doi.org/10.1016/j.psc.2018.10.004
  58. Dhopatkar N, Keeler JL, Mutwalli H, Whelan K, Treasure J, Himmerich H. Gastrointestinal symptoms, gut microbiome, probiotics and prebiotics in anorexia nervosa: a review of mechanistic rationale and clinical evidence. Psychoneuroendocrinology. 2023;147:105959. https://doi.org/10.1016/j.psyneuen.2022.105959
  59. Valles-Colomer M, Menni C, Berry SE, Valdes AM, Spector TD, Segata N. Cardiometabolic health, diet and the gut microbiome: a meta-omics perspective. Nature Medicine. 2023;29(3):551-61. https://doi.org/10.1038/s41591-023-02260-4
  60. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutrition. 2019;22(5):936-41. https://doi.org/10.1017/s1368980018003762
  61. Rauber F, Steele EM, Louzada MLdC, Millett C, Monteiro CA, Levy RB. Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016). PloS One. 2020;15(5):e0232676. https://doi.org/10.1371/journal.pone.0232676
  62. Figueiredo N, Kose J, Srour B, Julia C, Kesse-Guyot E, Péneau S, et al. Ultra-processed food intake and eating disorders: cross-sectional associations among French adults. Journal of Behavioral Addictions. 2022;11(2):588-99. https://doi.org/10.1556/2006.2022.00009