Danielle O’Regan looks at the role of the dietitian within family therapy for anorexia nervosa at the Maudsley Centre for child and adolescent outpatient eating disorders.
Dietitians are increasingly being recognised as important multidisciplinary team (MDT) members in the treatment of a variety of mental health conditions.1 However, the role of dietitians within child and adolescent outpatient eating disorders (CAEDs) treatment remains under-researched and is not well defined in treatment manuals.
The dietitian’s role in family therapy for anorexia nervosa (FT-AN) remains unclear regarding their level of involvement in treatment and timings of involvement.
Through working at the Maudsley Centre for CAEDs over the past year, I have been working with the team to think about how best to embed the dietetic role within the model. We have been working towards highlighting the vital role that dietitians can play in patients’ recovery through research.
Treatment models for child and adolescent eating disorders
FT-AN is the first-line NICE-recommended outpatient treatment approach for young people (<18 years) diagnosed with anorexia nervosa (AN), showing high recovery rates at 12 months and 18 months follow-up.2,3 FT-AN was first developed at the Maudsley in the late 1970s as an outpatient treatment model for AN. Early versions of the model did not include a dietitian as a direct member of the treating team, but since the 2016 version of the manual, the dietitian has been highlighted as a key team member.4
This is contrary to family-based treatment (FBT), where it is advocated that the dietitian should not be a member of the direct treating team as it is felt to undermine the treatment principle of parental empowerment. The FBT model follows the principle that parents have all the knowledge and skills they need to feed their child and support them to recover from their eating disorder, and any nutritional advice required can be delivered by the treating therapist.5 Criticism of this model has focused on the various nutritional issues that may arise during eating disorders treatment that are best supported and managed by specialist dietitians.6
My role within the Maudsley
Since May 2023, I have been working as the outpatient CAEDs dietitian within the team that developed FT-AN. The Maudsley Centre for CAEDs (MCCAED) is nationally and internationally renowned for clinical and research evaluation of psychological treatments for eating disorders and is commissioned to provide training nationally and internationally on FT-AN.
When I came into this position, the role of the dietitian within the team was significantly underfunded. Over the past six years, dietetics in MCCAED has grown from having one part-time dietitian to five dietetic posts (four full-time and one part-time) and two dietetic-led PhDs.
Within my first year in the role, I attended FT-AN training, observed the model in action and got to know the team to understand how best to further develop the dietetic role considering the additional funding. Some early successes have been updating the meal plans to be more culturally inclusive and in line with current best practices in eating disorders, such as being based on the plate-by-plate model and offering vegan and vegetarian standard meal plans.
I have provided training for all team members on nutrition topics such as veganism, intuitive eating, and updates on current nutrition research in eating disorders, to ensure all team members have up-to-date and evidence-based nutritional information. I have also worked with the team to embed a dietitian session within the multi-family therapy group/parent group and developed a dietetic care pathway to provide greater clarity on what types of patients may benefit from dietetic involvement.
Working in this role has brought multiple challenges, as it was very different to other models of eating disorder treatment I have worked with, such as specialist supportive clinical management. I was initially sceptical about the FT-AN approach and unsure about the idea of all dietetic appointments being joint with the clinician. However, on reflection, I can see the benefits this brings to the dietetic role. It helps strengthen the therapeutic alliance, presents the team as a united front, prevents the ‘bad cop’ role in which dietitians can sometimes be placed, as the advice is given by all treating team members, and reduces the chance of splitting. In this model, I feel the dietetic time is used more appropriately as the clinicians can undertake the check-ins on nutritional goals set in the dietetic appointment between sessions, keeping dietetic time impactful.
More time in this model is spent providing consultation to clinicians on smaller nutritional queries, ensuring that the whole team’s skills and knowledge are up to date and in line with best practice. As more team consideration is placed on when to involve the dietitian, it ensures that dietetic intervention is used appropriately rather than a ‘throw everything at it’ approach when a family becomes stuck in treatment.7 I have appreciated the clear goals for dietetic sessions, ensuring that families get the most out of the session at the right times in treatment.
Moving forward and research
To continue to advance the role of the dietitian within FT-AN, the Maudsley has supported me to begin a PhD. This is focused on building an evidence base for how to best utilise the dietetic role in the FT-AN model. An important part of this PhD will be exploring patient and parent experiences of the current model of providing nutrition advice. This will include asking their opinion on the current standardised meal plans and their experience of nutrition advice and education within the service.
Currently, all discussions around the benefits and risks of dietetic involvement are led by clinicians, so it will be an important step forward to bring patients’ and families’ voices into the conversation.7 I will also be exploring the dietetic perspective of working within FT-AN by undertaking qualitative interviews with dietitians. I aim to explore if they feel dietitians are sufficiently utilised within the current model and, if not, how this could be improved. I have begun recruiting for this study, and so far 11 dietetic interviews have been conducted.
One theme that has emerged within the dietitian interviews is the important role that dietitians play in increasing parental feeding confidence. This was highlighted by multiple participants as a key role for dietitians in FT-AN, including this observation: “From my experience, it was a lot of confidence building with parents. I think our input affects that… As the kind of expert in food and letting them know what they need, I think that was quite powerful as well.”
Through my PhD, I want to begin to explore parental feeding confidence as an outcome measure for evidencing how dietetic involvement can increase this. A validated tool to measure feeding confidence is the ecSatter inventory (ecSI 2.0). This tool explores parental feeding confidence across four main domains (eating attitude, food acceptance skills, internal regulation skills and contextual skills).8,9 Given that FT-AN is based on the principle that parents know how to feed their child and empowering parents to take back control of their child’s eating, it seems highly likely that parents with lower scores are more likely to struggle within this model.
This could be beneficial, as a recent study has highlighted that, currently, it is difficult to predict what young people will and will not need in terms of dietetic input at baseline and that levels of dietetic involvement were largely linked to lack of weight restoration during treatment.10 The ecSI 2.0 could be a valuable tool, as the interviewees highlighted a lack of outcome measures for dietitians working in eating disorders as a potential barrier to advancing the profession.
I am also exploring the hypothesis that lower levels of parental feeding confidence at assessment could be predictive of poorer treatment outcomes. If this proves to be correct, then could treatment outcomes for families with low levels of feeding confidence benefit from early dietetic intervention to increase their scores and treatment progress?
Feedback from the dietetic interviews indicates a desire for greater clarity and training specifically on the dietetic role within FT-AN. Interview participants reported feeling that the dietetic role in the FT-AN training was not discussed at length, and felt this left clinicians uncertain about how the role fits within the model. “I think there’s not a huge amount of guidance on what it does or doesn’t look like... It could be a very, very different role where it’s either under-utilised or it’s massively inappropriately overly utilised in other domains that aren’t just nutrition and dietetics,” said one.
Based on this early feedback, and our own experience at the Maudsley, we have made changes to the standard FT-AN training delivery. The training now includes an additional section covering how we use the dietetic role within our team, how clinicians can work with a dietitian to best utilise the role and distinguish between standard nutrition advice a clinician can deliver, and when more specialist dietetic input is needed. From 2025, we will also be delivering one-day training at the Maudsley specifically for dietitians, on working across FT-AN, FT-BN, ARFID and intensive day programmes. The training aims to support dietitians to integrate the role into the teams that they are working in, and provide greater clarity on where the role fits within an FT-AN model and across other outpatient treatment modalities.
Conclusion
Coming into the role at the Maudsley has presented both opportunities and challenges concerning the evolution of the dietetic role within the FT-AN model. However, my experience of working alongside the experts in FT-AN has been a positive one, including the team being open-minded and having some dynamic discussions around the future development of the dietetic role. I appreciate the team’s passion for evidence-based treatment and their support in building on the research base to demonstrate the impact that dietetic interventions have in this patient group. Continued research in this area will further evolve and embed dietetics into the FT-AN treatment model and champion the important role that dietitians play in improving patient outcomes.
References
- Burrows T, Teasdale S, Rocks T, Whatnall M, Schindlmayr J, Plain J, et al (2022) Effectiveness of dietary interventions in mental health treatment: a rapid review of reviews. Nutr Diet 79(3):279–90
- National Institute of Health and Care Excellence (2017) NICE Guideline (NG69) Eating Disorders: Recognition and treatment. Available online at: https://www.nice.org.uk/guidance/ng69. (accessed on 22 April 2024)
- Eisler I, Simic M, Hodsoll J, Asen E, Berelowitz M, Connan F, Ellis G, Hugo P, Schmidt U, Treasure J, Yi I, Landau S. A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa. BMC Psychiatry. 2016 Nov 24;16(1):422
- Eisler I & Simic M (2019) Family therapy for child and adolescent anorexia nervosa (FT-AN) manual. Unpublished
- Lock J., Le Grange D (2012) Treatment Manual for Anorexia Nervosa—A Family-Based Approach. 2nd ed. Guildford Press; New York, NY, USA
- Heafala, A.; Ball, L.; Rayner, J.; Mitchell, L.J (2021) What role do dietitians have in providing nutrition care for eating disorder treatment? An integrative review. J. Hum. Nutr. Diet. (34) 724–735
- Brennan C, Baudinet J, Simic M & Eisler I (2024) 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 (27) 16(5):670
- Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ (2007). Measuring eating competence: psychometric properties and validity of the ecSatter Inventory. J Nutr Educ Behav; 39:S154- 166
- Stotts J.L & Lohse B (2007) Reliability of the ecSatter Inventory as a Tool to Measure Eating Competence. Journal of Nutrition Education and Behaviour. pages S167-S170 10 Brennan, C.; Felemban, L.; McAdams, E.; Walsh, K.; Baudinet, J (2024) An Exploration of Clinical Characteristics and Treatment Outcomes Associated with Dietetic Intervention in Adolescent Anorexia Nervosa. Nutrients (16) 4117
