Don’t let the ‘eating’ in eating disorders be forgotten

Australian eating disorders dietitian and researcher Dr Caitlin McMaster reflects on the importance of dietitians in filling research gaps in the area. 

When I was at university and after I finished my dietetics degree, I wasn’t planning on working in the eating disorder (ED) field. However, I was fortunate to be offered a position at the Royal Prince Alfred Hospital ED day programme under the management of Dr Susan Hart in 2013.

From the infectious passion and commitment to the field that Susan instilled in me and our team, so began my career in EDs. Since then, I have had the privilege of working in several ED services across New South Wales, Australia, and in 2021 completed my PhD at the University of Sydney.

Prior to starting my PhD, I was lucky to have support to attend several national and international ED conferences. While these provided numerous learning opportunities, I always walked away from these meetings with the same questions – Where were the dietetic presentations/workshops? Where was the dietetic research? Where was the consideration of what role dietitians play or how they could add value to treatment services or research studies to improve patient outcomes?

Dietetic colleagues and I would have the same exasperated conversations in our workplace hallways and at professional development events – What about X that we do day-in, day-out with our patients? Why are these important skills and knowledge of ours overlooked or misunderstood?

It was apparent to me that having more well conducted research in the area could only help advocate for the importance of dietitians in ED treatment. I saw enrolling in a PhD as a contribution I could make, something to help chip away at the research gaps that are often cited as barriers to dietetic intervention being incorporated or recognised in ED care.

Between 2018 and 2021, I completed my PhD under the supervision of Susan, Professor Tracey Wade and Dr Janet Franklin, with invaluable contributions from other clinicians and researchers, including Professor Glenn Waller, Dr Chris Basten, Dr Mandy Goldstein and Jessica Ross. My body of research involved:

1.  Analysing current dietetic literature and nutrition-related information in manualised therapies^1,2
2.  Generating consensus-based guidelines for outpatient dietetic treatment of EDs^3,4
3.  Developing a manualised dietetic intervention for replication in future research⁵
4.  Exploring reasons why clinicians involved a dietitian in treatment⁶

My work also identified several barriers to the progress of evidence-based dietetic practice for EDs and the implementation of evidence-based dietetic practice in real-world clinical settings, including: gaps in clinicians’, consumers’ and carers’ understanding of the role of dietitians in ED treatment; dietetic research and expertise being overlooked in clinical practice and treatment manuals; and reluctance of clinicians to refer to dietitians because of issues such as patients’ ambivalence to engage with a dietitian or difficulties accessing a dietitian with ED expertise.

Some recommendations I made for future research to address this included conducting clinical trials to determine the acceptability and efficacy of outpatient dietetic intervention as part of multidisciplinary treatment, determining standardised language and outcome measures used in the reporting and evaluation of dietetic treatment, and exploring barriers and facilitators to patients engaging in dietetic treatment. I’m pleased to say there are several Australian dietitians currently conducting PhD research to help address some of these research gaps.

There are also several bigger-picture learnings that I have taken away from my PhD and subsequent work:

1. All research counts: Presenting, publishing and disseminating even seemingly small quality improvement or research projects such as case studies is still hugely important in contributing to the evidence base and providing a foundation for future research, advocating for the importance of dietetics and documenting dietitians’ clinical approaches
2. From little things, big things grow: In 2022, my colleagues Dr Susan Hart and Dr Gabbi Heruc formed the Eating Disorders and Nutrition Research Group (ENRG) at Western Sydney University to bring together researchers with an interest in nutrition and EDs. We now have 12 members, with two student members who are undertaking their PhDs in EDs. We hope to continue to attract research students and secure grant funding to carry out research project ideas in this area
3. We have broader impact and reach when we collaborate: A career highlight for me was being invited to contribute to the nutrition information provided in the treatment manual for CBT-T for EDs thanks to collaborations with Prof Tracey Wade and Prof Glenn Waller. Collaborating with clinicians and researchers who support the work of dietitians has been instrumental in bringing attention to and disseminating my work, even if it isn’t in a formal dietetic context, such as in a manualised psychological therapy in this case.

References

1. McMaster CM, Fong M, Franklin J, Hart S. Dietetic intervention for adult outpatients with an eating disorder: a systematic review and assessment of evidence quality. Nutrition Reviews. 2021;79(8):914-930.
2. McMaster CM, Wade T, Franklin J, Hart S. A review of treatment manuals for adults with an eating disorder: nutrition content and consistency with current dietetic evidence. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2021;26(1):47-60.
3.  McMaster CM, Wade T, FranklinJ, 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):1480-1495.
4.  McMaster CM, Wade T, Franklin J, Hart S. Discrepancies between Australian eating disorder clinicians and consumers regarding essential components of dietetic treatment. Journal of the Academy of Nutrition and Dietetics. 2022;122(8):1543-1557.
5.  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(5):1467-1481.
6. McMaster CM, Wade T, Franklin J, Waller G, Hart S. Impact of patient characteristics on clinicians’ decisions to involve dietitians in eating disorder treatment. Journal of Human Nutrition and Dietetics. 2022;35:512-522.