What Are the Best Nutritional Counseling Practices for AN Patients?

In one Delphi study, no consensus was reached on goal weights and family-based therapy.

Perhaps surprisingly, training in eating disorders is not part of the core curriculum of most dietetics programs. Because of this, registered dietitians (RDs) who specialize in treating patients with eating disorders may approach treatment based on their personal experiences rather than on evidence-based information. Even the American Academy of Nutrition and Dietetics has stated that advanced training necessary for working with patients with eating disorders must come from a combination of self-study, continuing education, and supervision by another experienced eating disorder specialist.

A Delphi Study

Anne M. Mittnacht, MPH, RD, and Cynthia M. Bulik, PhD, of the University of North Carolina, Chapel Hill, designed a study using Delphi methodology to determine if a consensus could be reached about the best nutritional counseling practices for treating patients with AN (Int J Eat Disord 2014; printed before publication). With the Delphi method, discussions are anonymous and web-based, making it easier for professionals to participate, and to freely express their opinions without being pressured to agree with other members of a group, as in a face-to-face panel discussion. The Delphi method has been used in many settings to reach consensus on topics or issues or definitions within their fields. Participants typically complete a series of iterative questionnaires, with a goal of reaching consensus.

Twenty-one RDs, all of whom had at least 5 years of experience counseling patients with eating disorders, participated in the study. Over a 10-week period the RDs completed 3 iterative questionnaires about nutritional counseling for patients with AN. Subsequent questionnaires were developed based on analysis of the responses to the first questionnaires; panelists were then asked to rank their level of agreement with these items.

The first-round questionnaire included 12 open-ended questions about nutritional counseling practices for patients with AN. Typical questions asked about addressing goal weights with patients and preferred eating plans. In the second round the investigators analyzed content from the 252 responses to the first questionnaire. Fifteen categories emerged and were included in a second questionnaire. The RDs were asked to rank each of the 15 topics using a 5-point Likert-like scale, from “strongly disagree” to “strongly agree.” In round 3, the responses were analyzed and carried over to the third questionnaire. Beneath each item the RDs could see their previous responses and a bar chart depicting the percentage of panelists who selected each ranking category.

Consensus was reached on most points

The majority of the RDs (95.2%) were female, had been working as RDs for an average of 21 years, and had specialized in eating disorders for an average of 14 years. Panelists achieved consensus on 47, or slightly more than one-third, of the 133 items included in the second and third questionnaires. The RDs unanimously agreed that a good patient goal-setting plan was to determine what a patient needs in order to be medically stabilized. Other areas of consensus included use of patient-centered counseling techniques to develop patient goals. When a patient first seeks treatment, goals should be modest, such as: (1) making patients aware of the signs of malnutrition that will improve with weight restoration and (2) setting eating plans, addressing body image and other psychological disorders. There also was unanimous consensus that treatment techniques should be based on evidence-based studies.

The panelists had conflicting views on implementing family-based therapy. And, although the panel agreed that RDs should be properly trained in psychotherapeutic techniques before trying them, conflicting views arose about just what this training should entail. Notably, there was disagreement about setting goal weights for adult patients. For children and adolescents, however, there was consensus on weight goal setting using growth charts.

The authors note that more studies are needed on how to counsel AN patients about nutrition. A better evidence base could lead to better care for these patients. The panel also suggested that another beneficial step would be implementation of a standard training and continuing education training for RDs. And, finally, to be effective in this area, nutritionists may face extensive counseling and psychotherapy training.