Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders.

RATIONALE, AIMS AND OBJECTIVES: Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment. METHOD: This was a qualitative exploratory study using semi-structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method. RESULTS: Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient-centred care, and working with stigma and ambivalence. CONCLUSIONS: Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision-making as able.

Credentialing for eating disorder clinicians: a pathway for implementation of clinical practice standards.

Advances are needed to ensure safe and effective treatment is available for people with eating disorders. Recently developed clinical practice and training standards for mental health professionals and dietitians represent a significant step in this direction by providing a consensus statement on eating disorder treatment as a foundation on which to build competent practice. This commentary argues that a credentialing system could promote implementation of these practice standards through formal recognition of qualifications, knowledge, training and professional activities to meet minimum standards for delivery of safe and effective eating disorder treatment. Drivers for credentialing include the imperative to provide safe and effective care, promotion of workforce development in eating disorder practice and, importantly, readily available and transparent information for referrers, consumers, and carers to identify health professionals credentialed to provide eating disorder treatment. However, a number of factors must be considered to ensure that credentialing does not restrict access to care, such as prohibitively narrow criteria to become credentialed, absence of pathways for education, training, or professional development opportunities, and lack of consultation with or endorsement by stakeholders of the credentialing criteria, application and approval processes, and ways of identifying credentialed practitioners. Further work, including development of credentialing criteria and aligned training opportunities, currently being undertaken by the Australia & New Zealand Academy for Eating Disorders and the National Eating Disorders Collaboration in consultation with stakeholders in the eating disorders sector and health professions will advance understanding of the feasibility of a system of credentialing for eating disorders within Australia and New Zealand. The availability of clinical practice and training standards, supported by implementation pathways, including credentialing of eating disorders practitioners, aim to improve quality of life, reduce financial burden, and close the treatment gap.

ANZAED practice and training standards for dietitians providing eating disorder treatment.

INTRODUCTION: Dietitians involved in eating disorder treatment are viewed as important members of the multidisciplinary team. However, the skills and knowledge that they require are not well characterised. Therefore, as part of a broader project to identify the key principles and clinical practice and training standards for mental health professionals and dietitians providing eating disorder treatment, the Australia & New Zealand Academy for Eating Disorders (ANZAED) sought to identify the key practice and training standards specific to dietitians. An expert working group of dietitians was convened to draft the initial dietetic standards. After expert review, feedback on the revised standards was then provided by 100 health professionals working within the eating disorder sector. This was collated into a revised version made available online for public consultation, with input received from treatment professionals, professional bodies and consumer/carer organisations. RECOMMENDATIONS: Dietitians providing treatment to individuals with an eating disorder should follow ANZAED's general principles and clinical practice standards for mental health professionals and dietitians. In addition, they should also be competent in the present eating disorder-specific standards based around the core dietetic skills of screening, professional responsibility, assessment, nutrition diagnosis, intervention, monitoring and evaluation. CONCLUSIONS: These standards provide guidance on the expectations of dietetic management to ensure the safe and effective treatment of individuals with an eating disorder. Implications for professional development content and training providers are discussed, as well as the importance of clinical supervision to support professional self-care and evidence-informed and safe practice for individuals with an eating disorder.

ANZAED eating disorder treatment principles and general clinical practice and training standards.

INTRODUCTION: Eating disorders are complex to manage, and there is limited guidance around the depth and breadth of knowledge, skills and experience required by treatment providers. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. General principles and clinical practice standards were first developed, after which separate mental health professional and dietitian standards were drafted and collated by the appropriate members of the expert group. The subsequent review process included four stages of consultation and document revision: (1) expert reviewers; (2) a face-to-face consultation workshop attended by approximately 100 health professionals working within the sector; (3) an extensive open access online consultation process; and (4) consultation with key professional and consumer/carer stakeholder organisations. RECOMMENDATIONS: The resulting paper outlines and describes the following eight eating disorder treatment principles: (1) early intervention is essential; (2) co-ordination of services is fundamental to all service models; (3) services must be evidence-based; (4) involvement of significant others in service provision is highly desirable; (5) a personalised treatment approach is required for all patients; (6) education and/or psychoeducation is included in all interventions; (7) multidisciplinary care is required and (8) a skilled workforce is necessary. Seven general clinical practice standards are also discussed, including: (1) diagnosis and assessment; (2) the multidisciplinary care team; (3) a positive therapeutic alliance; (4) knowledge of evidence-based treatment; (5) knowledge of levels of care; (6) relapse prevention; and (7) professional responsibility. CONCLUSIONS: These principles and standards provide guidance to professional training programs and service providers on the development of knowledge required as a foundation on which to build competent practice in the eating disorder field. Implementing these standards aims to bring treatment closer to best practice, and consequently improve treatment outcomes, reduce financial cost to patients and services and improve patient quality of life.

Balancing nutrition management and the role of dietitians in eating disorder treatment.

The symptoms of starvation and dietary restriction are often the subject of targeted intervention in evidence-based treatments across eating disorder diagnoses and treatment models. Despite the level of attention given to these symptoms of clinical malnutrition, they are often treated by health professionals with no nutritional qualifications and in a non-clinical manner in the outpatient setting, with dietitians having no defined role in manualised treatment models. Recently the Australia & New Zealand Academy for Eating Disorders (ANZAED) published practice and training standards for dietitians to help characterise their role in eating disorder treatment. Since malnutrition, secondary to dietary restriction, is a clinically significant nutritional diagnosis that co-occurs in eating disorder presentations, this commentary proposes that dietitians are ideally-positioned to assess and advise on the clinical aspects of malnutrition as a key member of the multidisciplinary team. Food is a central focus in eating disorder treatment, suggesting that nutritional care needs to be addressed by a dietitian alongside the psychological aspects of care that are addressed by a mental health professional.

A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders.

BACKGROUND: Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts. OBJECTIVE: To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs. DESIGN: This was a retrospective pre-test-post-test study. PARTICIPANTS/SETTING: One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013. MAIN OUTCOME MEASURES: Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined. STATISTICAL ANALYSIS PERFORMED: χ2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols. RESULTS: Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391). CONCLUSIONS: A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.