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.

Exploring perceived training and professional development needs of Australian dietetic students and practising dietitians in the area of eating disorders: a focus group study.

BACKGROUND: Timely diagnosis and treatment of eating disorders (EDs) are essential for achieving the best possible outcomes, and dietitians have an important role in the multidisciplinary team. ED-specific training has been shown to enhance the knowledge, mental health literacy and confidence of health professionals in providing patient treatment. However, the ED-specific training needs of dietitians have yet to be determined. This study aimed to explore the perceived readiness of dietitians and student dietitians to treat patients with EDs; to identify the key training components that would enhance their confidence in delivering ED-specific treatment; and to examine any barriers associated with engagement in ED-specific professional development. METHODS: A semi-structured question guide was developed by researchers to elicit information from six virtual focus groups consisting of a purposive sample of practising dietitians and student dietitians enrolled in their final year of an Australian tertiary accredited dietetic program. Members of professional organisations were approached to participate via email; and a recruitment flyer was promoted on various social media platforms. Discussions were recorded, transcribed verbatim and analysed qualitatively using inductive thematic analysis. RESULTS: Thirty-eight participants (26 dietitians, 12 student dietitians) were recruited, mean age of 32.5 years ± 11 SD. Three major themes emerged: (1) reluctance to practice in EDs, which was associated with limited ED-specific training at university, lack of clinical guidelines, mental health complexities of patients with an ED, ambiguity regarding the dietitian's role, systemic complexities with ED care, and beliefs of health professionals; (2) the need for additional ED-specific training and clinical supervision both during and after university, with the focus on identification, assessment, management and treatment, mental health literacy, and counselling skills, identified as an essential component to improving professional confidence and competence; (3) limited awareness and access/supply of ED-specific training opportunities were found, which included the financial cost of training/clinical supervision, and limited access to suitable clinical supervision. CONCLUSION: Dietitians currently practising in the workplace and dietetic students perceive that enhanced ED-specific training during university and after graduation is essential to work with patients confidently and competently with EDs. This research has implications for Australian university dietetic programs and workforce development. This study aimed to explore the perceptions and readiness of dietitians and student dietitians to treat patients with eating disorders (EDs); to identify the key training components that would enhance their confidence and competence in delivering treatment; and to examine any barriers associated with engaging in ED-specific professional development. Twenty-six dietitians and twelve dietetic students participated in six virtual focus group discussions, which identified three main themes: (1) reluctance to practice which was associated with limited ED-specific training at university, lack of clinical guidelines, mental health complexities of patients with an ED, ambiguity regarding the dietitian's role, systemic complexities with ED care, and beliefs of health professionals; (2) the importance of engaging in ED-specific training, beyond an introductory level, during university and after graduation to confidently and competently work with patients with EDs; (3) barriers to accessing further ED-specific training and clinical supervision were found, including poor awareness of training opportunities, high financial cost of training/clinical supervision, and limited access to obtaining suitable clinical supervision. Results from this study provide insight into the ED-specific training needs of practising and student dietitians. This research has value for university programs and workforce development.

A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial.

BACKGROUND: The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat). METHODS: Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds. RESULTS: At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay. CONCLUSIONS: The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations. TRIAL REGISTRATION: ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.

Patients hospitalised with anorexia nervosa require nutrition support as part of their treatment, whilst refeeding complications are prevented. Of particular concern, is the reintroduction of carbohydrate to malnourished patients, which has been proposed to cause a surge in insulin levels and disturbance in electrolytes, particularly a decrease in blood phosphate levels. This double-blinded randomised controlled trial measured the occurrence of low phosphate blood levels and other refeeding complications, in adolescent and young adult patients hospitalised with anorexia nervosa. These patients were provided either a lower carbohydrate/high fat feed (28% carbohydrate, 56% fat) or a standard enteral feed (54% carbohydrate, 29% fat). Fewer patients in the lower carbohydrate/high fat feed group (5/14) than standard feed group (9/10) developed a low phosphate level. There was no significant difference in weight gain, number of days to reach medical stability, occurrence of hypoglycaemia, or hospital length of stay.

A benchmarking study of home enteral nutrition services.

BACKGROUND & AIMS: Patients receiving home enteral nutrition (HEN) via an enteral feeding tube often have complex healthcare requirements. There is limited information regarding how HEN care is provided within Australia and New Zealand. This study aimed to investigate the characteristics of HEN services and the provision of nutrition care to individuals receiving HEN within Australia and New Zealand. METHODS: A cross-sectional study, surveying lead HEN dietitians for HEN services was conducted from the period 09 July 2019 to 20 September 2019 inclusive. An online survey was used to obtain data relating to the demographics, funding and clinical resources of respondents' HEN services. Services were benchmarked against a HEN service implementation checklist adapted from the Agency for Clinical Innovation (ACI). RESULTS: Responses were received from 107 HEN services, with an estimated combined population of 7122 HEN patients. Services were predominantly government-funded (n = 102, 95.3%) and operated from acute hospitals (n = 57, 53.3%). The reported combined cost of all HEN equipment to the patient ranged from $0-$77 per week or $0-$341 per month. Fifty-two services were reported to have a dedicated HEN dietitian/coordinator, which was positively associated with the undertaking of quality improvement activities (p = 0.019). Mean compliance to the ACI HEN implementation checklist was 70.4% (±15.7%) with a range of 13.0-98.2%. Mean compliance was significantly higher in services with a HEN dietitian/coordinator than services without one (75.5% (±12.0%) vs 64.3% (±16.6%); p < 0.001). CONCLUSIONS: This study provides detailed information regarding the characteristics of HEN services and nutrition care provided to enterally-fed patients across Australia and New Zealand. The majority of HEN services are not adhering to the ACI HEN service guidelines and there is considerable variation in cost burden for consumers indicating inequitable delivery of care to patients.

Understanding training needs in eating disorders of graduating and new graduate dietitians in Australia: an online survey.

BACKGROUND: Following recent reforms by the Australian Government to the Medicare Benefits Schedule, people living with a diagnosed eating disorder (ED) in Australia have greater access to dietetic services. However, new graduate dietitians anecdotally lack confidence to provide appropriate interventions to support patients with an ED. Therefore, this cross-sectional study aims to explore the perceived confidence, and educational and professional development needs of student dietitians and new graduate dietitians in the area of EDs. METHODS: An online survey with 17 questions was designed, consisting of a combination of discrete (yes/no) questions, free text, ordered scales and 5-point Likert scales. Student dietitians, and first- and second- year graduates (n = 1456) were approached via email as potential participants, from the professional organisation Dietitians Australia member list. Survey data was analysed using descriptive statistics and odds ratios. RESULTS: In total, 150 surveys were completed, with a response rate of 10.3%. Respondents reported a lack of confidence in managing patients with an ED and implementing ED treatment approaches (81 and 95%, respectively). However, participants previously exposed to patients with an ED, such as anorexia nervosa, were 4.7 times (95% CI 1.72, 12.97) more likely to be confident compared to those not exposed to patients with an ED. The majority of respondents (37%) stated they would seek assistance from other dietitians, and develop their skills via online webinars (27%) and workshops (25%). CONCLUSIONS: This survey identified that final year dietetics students and new graduate dietitians perceive lower levels of confidence to practice in the area of EDs. The desire for further ED-specific training and education was reported.

Evaluation of patient quality of life and satisfaction with home enteral feeding and oral nutrition support services: a cross-sectional study.

Objective The aims of the present study, in home enteral nutrition (HEN) patients, were to assess patient satisfaction with the service and quality of life (QOL) scores, and to compare QOL scores in HEN patients with general Australian population values. Methods Self-administered voluntary questionnaires for the present cross-sectional study were mailed out to 322 eligible participants registered with HEN for >5 months. The questionnaires used included a patient satisfaction survey and a validated QOL questionnaire. Data analysis consisted of cross-tabulation, Chi-squared tests and t-tests. Results There were 112 participants. Patients reported satisfaction with information received before discharge (86%), support received after discharge (74%), expertise of the health professional (87%), access to health professionals experienced with HEN (74%), communication between health professionals (74%), costs of HEN supplies (52%) and delivery of HEN supplies (88%). QOL scores related to physical, psychological, social and environment domains were significantly lower in HEN patients than in the Australian reference population (P<0.001). There was no significant difference in QOL and health satisfaction across different clinical areas (0.737 and 0.316, respectively). Conclusion Overall, participants were satisfied with HEN services. Participants had lower QOL scores compared with the Australian general population. Improvements to the HEN service were suggested, including sooner follow-up after hospital discharge; more frequent reviews for long-term patients; and the availability of a multidisciplinary team to manage HEN patients. What is known about the topic? Malnutrition is a common problem in Australian hospitals. Many patients require nutrition support to maintain or improve their nutrition status because of inadequate oral intake, malabsorption of nutrients or because of a disease process. Nutrition support is commonly started in the in-patient setting and, because of faster patient discharge from hospital, HEN is a cost-effective and reliable way of treating patients who continue to need nutrition support after hospital discharge. Inconsistencies exist in service provision of HEN because there is no national or state-wide standardisation of services. Australian studies that have evaluated patient satisfaction with HEN services are lacking. This is of particular importance because HEN service use is increasing. What does this paper add? This study reveals that patients receiving HEN therapy are mostly satisfied with the service provided. Patients surveyed have expressed important aspects of the HEN service include follow-up and advice from health care professionals, low price and home delivery of supplies, emphasising the importance of adequate clinical services, supply and delivery of HEN. QOL is poorer in the HEN patient population compared with the general Australian population. What are the implications for practitioners? Standardisation of HEN services is important to ensure uniformity in service provision to HEN patients. Health services adhering to best practice guidelines for HEN will result in the provision of adequate quality of care, and subsequently improved patient satisfaction and adherence to HEN therapy. Adequate service provision and appropriate monitoring and review of HEN patients in the community may also contribute to better health outcomes and better QOL for patients.

An evaluation of current home enteral nutrition services at principal referral hospitals in New South Wales, Australia.

OBJECTIVE: This cross-sectional study investigates the home enteral nutrition (HEN) services of public principal referral hospitals in NSW, Australia, comparing their services to best practice guidelines for HEN. METHODS: HEN service processes were investigated using an online questionnaire and telephone interview with the dietitian primarily working with HEN at each hospital. RESULTS: Participating hospitals reported a total of approximately 3200 HEN patients, 76% required oral nutrition support. Only 69% of hospitals had a dietitian allocated to their HEN service and no hospitals had established multidisciplinary teams to manage HEN patients. Post-discharge follow-up, as recommended for tube fed and oral patients, was achieved by 8% and 15% of hospitals respectively. Forty-six per cent of dietitians were satisfied and 46% of dietitians were dissatisfied with current HEN services provided, and reported the following improvements were required: increased clinical resources allocated to HEN dietitian/coordinator; increased outpatient services (home visits, outpatient clinic, multidisciplinary clinic); and an efficient registration process and database. CONCLUSIONS: HEN services among participating hospitals are inconsistent, demonstrating gaps in service provision. Baseline assessment scores varied, with an average of 61% of recommendations currently in use. Best practice guidelines are not firmly adhered to due to limited funding and allocated resources for HEN.