Raising Awareness of Dietitians Working in Eating Disorder Services in Scotland.

By

Jacqueline McConnell
Lead CAMHS Dietitian, Connect Eating Disorders Team, NHS Glasgow & Clyde (GG&C)
Jacqueline.McConnell@ggc.scot.nhs.uk

Jean Corr
Advanced Dietitian, Anorexia Nervosa Intensive Treatment Team (ANITT), NHS Lothian
Jean.corr@nhslothian.scot.nhs.uk

We both agree that writing this blog for the world’s first Dietitians Week is a fantastic opportunity to raise awareness of the work and specialist role of dietitians within eating disorders services. Dietitians are essential members of the multidisciplinary team and are involved in the assessment, treatment and monitoring of patients with Anorexia Nervosa, Bulimia Nervosa and Atypical Eating Disorders or Eating Disorder Not Otherwise Specified
http://www.who.int/classifications/icd/en/bluebook.pdf.

Background
Through talking about our work we want to let people know what we do on a daily basis within children’s and adult services, and highlight additional developmental and strategic elements. However, before we begin it might be worth highlighting some basic facts about Eating Disorders:
• Eating disorders affect children, adolescents and adults.
• Eating disorders affect males and females.
• Eating disorders are a serious mental health illness, and if left untreated can carry a high risk to physical health.
• Poor eating patterns, rules and unhealthy views about food are really the symptoms of an eating disorder, not the cause.
• The SCOFF is a validated questionnaire that can be used with adults to help determine whether someone has an eating disorder.
• People can recover from eating disorders but the road to full or partial recovery varies enormously for each patient and it can take many years.

Services for Children and Young People

The Scottish CAMHS Dietitians Group
The Scottish Child and Adolescent Mental Health Service (CAMHS) Dietitians are a growing group of Scottish dietitians with a specialist interest in young people with eating disorders and other mental health conditions.

The group recently met in Glasgow and by utilising video conferencing facilities were able to communicate and share practice, knowledge and service developments with CAMHS Dietitians across the UK. This was so successful that a virtual meeting now takes place twice yearly. The focus of the recent meeting was the dietitians role in working with young people with eating disorders. The agenda included new, soon to be published research into re-feeding syndrome; the dietitians role in family support and meal time management; and dietitians’ experiences of working with a home intensive treatment team.

FBT
Family Based Treatment (FBT) is the current evidence-based treatment for young people diagnosed with anorexia nervosa and atypical anorexia nervosa. FBT is based on the belief that the family are a vital resource in a child’s successful recovery. It was developed in The Maudsley Hospital in London in the 1980s and is sometimes known as “Maudsley Approach”.

CAMHS services across the whole of Scotland have now been trained by Professor Lock in the FBT model and with a Scotland wide focus on FBT implementation I’m sure our specialist dietetic role will continue to be on the agenda as services evolve.

Dietetic Role
Working as part of the Connect Eating Disorders team in Glasgow, my role involves the nutritional assessment of young people in CAMHS with an eating disorder. The initial assessment focuses on the re-feeding assessment and forms part of the overall medical risk assessment for the young person:

The initial dietetic assessment gathers information on:
• Weight history, percentage weight loss, rate of weight loss and % weight for height
• Calculating healthy weight ranges for young people using 95-100% weight for height and assessing current growth status using WHO Growth Charts
• Assessing the behaviours of the Eating Disorder, for example calorie restriction, self induced vomiting, use of laxatives and over exercise
• Assessment of dietary intake, potential nutrient deficiencies and risk of re-feeding syndrome and advice on multivitamin replacement and biochemistry monitoring
• Physical impact of the eating disorder, for example on menstruation and bone health
• Calculating nutritional requirements
• Advising on diagnosis and treatment planning

With FBT being adopted across most health boards in Scotland the majority of young people will now have the opportunity to be treated with FBT and the dietitian can support this treatment and consult with families and clinicians when further advice is needed.

For more information on the risk assessment for young people with eating disorders please see Junior Marsipan guidance at
http://www.rcpsych.ac.uk/files/pdfversion/CR168.pdf

Individual Dietetic Work
Dietitians also have an essential role in the treatment of those young people for whom FBT is not an option, and where individual dietetic work and psychological therapies are more appropriate. This input is based predominantly around psycho-education covering behavioural, nutritional and physiological topics, supporting the patient with food planning and achieving their dietary goals.

Specialist In-Patient Units
Dietitians play an essential role within specialist inpatient adolescent units. Across Scotland we have Caledonia House at Yorkhill Hospital in Glasgow (under 12s), The West of Scotland Regional Adolescent In-patient unit in Skye House on the Stobhill Hospital site in Glasgow (12-18 years), The Young Peoples Unit (YPU) in Dundee (12-18 years), Edinburgh YPU and intensive treatment day service, The Lowitt Unit day service at Aberdeen’s Children’s Hospital and Dudhope in Dundee.

The dietitian provides a key role in these units within the eating disorder programme and will oversee nutritional assessment, re-feeding assessments, calculation of nutritional requirements, food planning, Nasogastric feeding, meal time support groups and meetings with family to support the young person though their in-patient journey and transition back into the community.

With the implementation of FBT, improved access to intensive day services and home intensive treatment teams, the aim is to keep young people out of hospital by encouraging treatment at home in the community.

Developments for Dietitians in Non eating disorders CAMHS
Most services across the UK have limited capacity for non eating disorders CAMHS referrals. However, we recently had the exciting addition to our team of a full time Specialist CAMHS dietitian. This is a clinical and development post, with high demand for dietetic input for non eating disorder patients with mental health problems such as Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) and we are in process of auditing growing numbers of referrals, developing referral criteria and nutritional pathways of care. This development and audit within NHS GG&C will hopefully add to practice in other areas of Scotland and the UK.

Working with young people with eating disorders is a challenging role but one that is very rewarding and enjoyable. Our mission is full recovery for all children and adolescents with eating disorders. It challenges clinical and communication skills, requires multidisciplinary working and involves meeting regularly with young people and working collaboratively with parents to ensure they are in a co-therapeutic role throughout assessment, treatment and discharge

Adult Services

The main emphasis for the Dietitian is to treat all people as individuals at each stage of treatment and by working together the dietitian and the individual will create a care plan with clear aims and goals which are realistic and achievable.

How can Dietitians help in the treatment eating disorders?
Similarly to services for children and young people, dietetic treatment is provided to adults in both inpatients and outpatients settings alongside psychological therapy and medical monitoring. Dietitians working in adult services are also specialised in assessing nutritional requirements and work collaboratively with patients to help them achieve individual goals which may be weight gain, weight maintenance or developing a more healthy or regular eating pattern. By ensuring we are up-to-date with a wide spectrum of nutritional information and resources, we can provide accurate, evidence based information to patients and offer specialist advice for those with additional conditions such as diabetes or food allergies.

Generally the role of the Dietitian in adult care is divided into the following areas:
• Dietetic Assessment
• Treatment planning
• Development of meal plans
• Dietary recommendations
• Practical Support
• Family work
• Support for carers and families
• Nutrition Education

Dietetic sessions are usually delivered as 1:1 sessions in a specialist setting or in a community clinic. All are tailored to the individual’s needs and are matched to the complexity of their illness. However, group work is recognised as a useful treatment model and most services provide modules in Nutrition Education as part of established Eating Disorder groups.

The Impact of Services
Working with patients who suffer from an Eating Disorder is challenging but enormously rewarding and I thought I would share with you a couple of quotes from some people I have worked with over the years.

‘I have found the sessions very informative, helping me to make positive changes to my diet’.

‘I feel the treatment I have received has given me a better idea of what I am supposed to eat and how often. It’s just a case of putting it into practice and doing it at my own pace’.

‘I got lots of very helpful information that related to my illness and my needs. I also have lots of leaflets that I can refer to when I need. I found follow up appointments very helpful as it was good to understand I was on the right road to recovery’

Developmental and Strategic Work

Eating Disorders Week
In February 2014 the Scottish Parliament led and hosted Eating Disorders week; see http://www.dennisrobertsonmsp.net/edaw14/ for more details. Various workshops and presentations were delivered throughout the week, raising awareness of the prevalence of eating disorders and the importance of early identification and treatment. During this week there was a fantastic representation of dietitians from across eating Disorder Services in Scotland networking and sharing practice.

NDR-UK and SDEDCF
There a several resources available through the NDR-UK (Nutrition and Diet Resources UK) to support dietetic psycho-education. These were developed and are reviewed by a national network of Scottish dietitians; The Scottish Dietitians Eating Disorders Clinical Forum (SDEDCF). The SDEDCF is a network of approximately 45 Eating Disorder Dietitians who work all over Scotland and meet 3 times a year. The overall aim of the group is to provide consistent best practice in the treatment of Eating Disorders across Scotland. This is achieved by providing members with a real opportunity to: learn and develop new skills; keep up-to-date with the latest evidence; sharing practice and supporting one another, which is especially important for those working in isolation.

Our next SDEDCF meeting is taking place during Dietitians Week (on June 11th) and will focus around 4 main themes:
• Reporting back from the BDA Mental Health Group 2 day conference (9-10th June) and the feedback from Child and Adolescent Mental Health Service Dietitians video conference in May.
• Reviewing the NDR-UK ‘Inside Eating’ diet sheets and sharing resources (Link to NDR-UK)
• Fluid and nutritional requirements
• Case presentation and review of recent journal articles

Conclusion
We both hope you have enjoyed reading this blog and that it has offered some insight into the support Dietitians offer to patients with Eating Disorders in Scotland. We also hope it helps to raise awareness of eating disorders and the importance of early identification.
If you would like more information about any of the content or you would like to get more involved in this area of work please contact us.

References
NHS Quality Improvement Scotland 2006. Eating Disorders in Scotland: Recommendations for Management and Treatment.

Morgan, J. F., F. Reid and J. H. Lacey. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ.
319: 1467 – 1468, Dec 1999.

 

 

 

 

 

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