Development and Preliminary Evaluation of a Nutritional Psycho-Education Group in a Community Eating Disorders Service

Special Article - Eating Disorders

Ann Nutr Disord & Ther. 2016; 3(1): 1031.

Development and Preliminary Evaluation of a Nutritional Psycho-Education Group in a Community Eating Disorders Service

Khatun R¹, Conroy M¹*, Jeffereys K¹ and Frampton IJ1,2

¹Eating Disorders Service, Cornwall Partnership NHS Foundation Trust, UK

²Department of Psychology, University of Exeter, UK

*Corresponding author: Conroy M, Eating Disorders Service, Cornwall Partnership NHS Foundation Trust, Truro Health Park, Truro. TR1 2JA, UK

Received: October 07, 2016; Accepted: November 11, 2016; Published: November 14, 2016


Introduction: Restoring healthy attitudes towards food choice and nutrition are at the core of successful treatment for eating disorders. However, little is known about what constitutes effective nutritional psycho-education for service users. This study evaluates a dietitian-led nutritional psycho-education group treatment for adults with eating disorders, specifically Anorexia Nervosa, Bulimia Nervosa and Eating Disorder Not Otherwise Specified.

Materials and Methods: Thirty-six service users attended a Food Choices group and completed questionnaires (a Food Choices Quiz, Personal Feedback Scale and Hopes and Worries Worksheet) before and after the group. Individual changes in scores were analyzed using a within-subjects design and written hopes and worries statements were reviewed using thematic analysis.

Results: Participation in the group was associated with significant increases in scores on the Food Choices Quiz and Personal Feedback scales of knowledge, confidence, trust, and skills to plan and eat healthy meals. Core themes were identified within the Hopes and Worries Worksheet reflecting factors about the group itself, food and eating, health, control and capacity (to believe in self, trust in others, learn and change).

Discussion: These data provide empirical support for the clinical effectiveness of a dietitian-led nutritional psycho-education group in enhancing adult service user understanding and positive attitudes towards healthy food choices. Further studies of variants of this intervention for children with eating disorders and their parents, and web-based delivery are warranted.

Keywords: Eating disorders; Psycho-education; Dietetics


Anorexia Nervosa (AN) is a serious psychiatric illness that primarily affects girls and young women. The salient features of AN are severe weight loss, body image disturbance, overvalued focus on shape and weight, and fear of fatness. Mortality, estimated to be at a rate of 5% per decade of illness [1], is amongst the highest of any psychiatric disorder [2], with risk increasing with chronicity. Inpatient treatment programs are largely successful in achieving the initial treatment aim of weight restoration. However, relapse is common, and the rate of re-hospitalization within a year after discharge is estimated to be as high as 50% [3].

Patients with AN restrict their intake of food, thereby decreasing energy and nutrient intake. In the short term, hospitalization changes eating behaviors dramatically: by the end of a patient’s hospital stay, daily food intake can exceed 3000kcals [4]. Similarly, it has been shown that patients’ per-meal calorie consumption increased during weight restoration treatment but nevertheless remained substantially less than the average consumed by healthy control participants [5]. At the beginning of admission, patients given a free choice and multiple food options had a mean intake per meal of 364kcals, which increased significantly to 516kcals [6]. Again, healthy participants consumed significantly more, at over 750kcals per meal.

Although significant improvement on most psychological measures is realized with weight gain, often to normal levels [7], weight restored patients often still struggle with food choice and caloric intake. Specifically, dietary choices made by weight-restored patients on an inpatient unit are consistently lower in energy density and diet variety [6]. When patients were asked to choose their own menus, they consumed significantly fewer calories than controls, and interestingly reduced calories from fat [8]. These results suggest that nutrition remains quite abnormal in patients despite substantial weight gain and improvements in many psychological characteristics following successful weight restoration treatment.

Bulimia Nervosa (BN) is characterized by episodes of recurrent binge eating accompanied by inappropriate compensatory behaviors such as self-induced vomiting. When patient participants were observed eating a non-binge meal (an amount of food that they could consume without needing to purge) they ate significantly fewer calories compared to a control group [9]. Moreover, individuals with BN also markedly restrict food intake between meals. Consequently the following destructive pattern emerges, whereby the individual binge-eats, then restricts caloric intake in an attempt to compensate, appetite increases, inadvertently encouraging another binge eating episode. Treatment aims to interrupt this restrict-binge-purge cycle by encouraging patients to follow regular balanced eating; a major component of Cognitive Behavioural Therapy (CBT), the most effective psychological treatment for BN [10].

Effective nutritional counseling (consisting of meal planning, nutritional education and weekly weighting) typically incorporates psycho-educational and supportive elements [11]. Modified nutritional counseling incorporating psychological assessment and reformulation increases patients’ motivation to change [12].

A community-based Eating Disorders Service serving a large rural population in the south west of the UK has developed an integrated treatment approach whereby group and individual therapy (i.e. cognitive behavioural therapy, dialectical behavioural therapy, family therapy etc) and dietetic interventions are utilized at different stages of a single therapeutic plan. Since 2012, all new referrals are invited to attend our dietitian-led nutritional psycho-education group, Food Choices, at the beginning of treatment in line with the UK National Collaborating Centre for Mental Health [13] recommendation that nutritional psycho-education should be a standard part of treatment for patients with eating disorders.

Recent findings suggest characteristic abnormalities in eating behavior persist following intensive and lengthy care and, as a consequence, re-hospitalization rates remain high. Inpatient programs typically provide varied diets to promote the restoration of a healthy body weight but it is unclear if they always offer education around healthy food choices. Eating disorders include restricting caloric intake and avoidance of certain food groups, typically fat, starchy foods and sugars. Therefore, a psycho-educational intervention, to improve knowledge about healthy food choices may enhance our ability to treat these challenging illnesses.

In the absence of scientifically-established nutritional treatment standards in the UK, the present study was designed to investigate the impact of attending a psycho educational Food Choices group, for service users with a DSM-IV diagnosable eating disorder (i.e. Anorexia Nervosa, Bulimia Nervosa or Eating Disorder Not Otherwise Specified). We predicted that participation in the group will result in service users: i) increasing their knowledge about regular balanced eating, basal metabolic rate and body composition; ii) feeling more supported and better skilled to challenge their disordered eating; and iii) addressing their hopes and worries concerning healthy food choices.

Materials and Methods


In total seventy-eight service users attended the Food Choices group between May 2012 and May 2015. Thirty-six adult service users (35 female; 1 male) aged 17 and above (mean age = 30, range 17-55 years) completed both pre and post measures. Demographic variables including age, sex, and Eating Disorder (ED) diagnosis are collected at initial assessment for all service users and collated as part of routine clinical referral statistics. At this stage we also collected Global Eating Disorder Examination - Questionnaire Version - EDE-Q [14], scores ranged from 0.806 to 5.638, and Body Mass Index (BMI) ranged from 13.89 to 32.38, see Table 1.The EDE-Q is a validated questionnaire assessing ED characteristics including Restraint, Eating Concern, Shape Concern and Weight Concern. The sub-group who completed the full set of measures did not differ from the remainder of the attendees in distribution of eating disorder subtype, Age, EDE-Q score or Body Mass Index (BMI, see Table 1); we therefore conclude that the data are representative of all attendees. In both sub-groups EDE-Q scores spanned the ‘average’ to ‘clinically significant’ range and BMI spanned the ‘severely underweight’ to ‘obese’ range.