Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60

https://doi.org/10.1007/s40519-020-00850-6

REVIEW

A review of treatment manuals for adults with an eating disorder:

nutrition content and consistency with current dietetic evidence
Caitlin M. McMaster1 · Tracey Wade2 · Janet Franklin3 · Susan Hart1,4

Received: 18 November 2019 / Accepted: 14 January 2020 / Published online: 30 January 2020
© Springer Nature Switzerland AG 2020

Abstract
Purpose This study aimed to summarise the nutrition and food-related content of treatment manuals for adults with eating
disorders (EDs) and assess the degree to which this information conforms with current guidelines and literature.
Methods Treatment manuals for adults with an ED were identified by conducting an online search of Internet book dealer
Amazon and University of Sydney library catalogue as per methods used in previous reviews of self-help patient resources.
The nutrition and food-related content of these manuals was extracted and reviewed independently by two reviewers using
a criteria based on current best evidence to date regarding dietetic treatment for EDs.
Results Twenty-two manuals met inclusion criteria, 20 (91%) of which contained some degree of nutrition and food-related
content. Two manuals (9%) included content written by a dietitian, six (27%) included citation of dietetic literature to support
the recommendations made and eight (36%) recommended a dietitian be consulted as part of a multidisciplinary approach to
treatment. Thirteen manuals (60%) contained nutrition and food-related information not substantiated by current evidence.
Conclusion It is common for treatment manuals for EDs to contain nutrition and food-related content. However, most of the
authors of the 22 manuals identified did not appear to collaborate with a dietitian in writing this content or cite peer-reviewed
literature to substantiate dietary advice given. Consistent with current clinical practice guidelines, greater collaboration
between dietitians and clinicians is required to develop, evaluate and disseminate evidence-based approaches to dietetic
management.
Level of evidence Level V, narrative review.

Keywords Dietetics · Feeding and eating disorders · Nutrition therapy · Psychotherapy

Introduction prevent achievement and maintenance of optimal nutrition sta-

tus [1]. This process should result individually tailored nutri-
The role of the dietitian in the treatment of eating disorders tion care plans that: correct nutritional deficiencies and promote
(EDs) is to identify and assess the severity of malnutrition, dis- optimal nutrition status; discuss the role of eating and adequate
ordered eating patterns and knowledge and skill deficits that nutrition in physical and mental well-being; and provide nutri-
tion education to challenge inaccurate beliefs about food [1–4].
Current clinical practice guidelines recommend dietetic
* Caitlin M. McMaster assessment, education and intervention as part of the mul-
caitlin.mcmaster@sydney.edu.au
tidisciplinary treatment of adults with EDs [5–7]. In prac-
1
Boden Collaboration for Obesity, Nutrition, Exercise tice, involvement of a dietitian may also liberate therapists
and Eating Disorders, University of Sydney, Sydney, NSW, from ED patients’ queries about food and nutrition, enabling
Australia greater focus on underlying psychological issues [8, 9]. The
2
Discipline of Psychology, College of Education, Psychology importance of dietetic treatment being delivered alongside
and Social Work, Flinders University, Adelaide, SA, psychotherapy has also been recognised in the expansion of
Australia
government-funded service provision of dietetic intervention
3
Metabolism and Obesity Services, Royal Prince Alfred in Australia from November 2019.
Hospital, Sydney, NSW, Australia
However, in clinical practice, several barriers exist to the
4
Nutrition and Dietetics Department, St Vincent’s Hospital, delivery of multidisciplinary care involving evidence-based
Sydney, NSW, Australia

13
Vol.:(0123456789)
48 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
dietetic treatment delivered by a dietitian. First, there is
currently a paucity of literature to guide content of dietetic
intervention for patients with an ED. As shown in Table 1,
current recommendations fall into one of two categories: (1)
broad recommendations given in treatment guidelines [2,
3, 5–7]; and (2) key publications describing nutrition and
dietetic practice in the field of EDs [1, 4, 10–14]. Further-
more, Mittnacht, Bulik [12] showed there is poor consensus
amongst specialist ED dietitians regarding components of
dietetic treatment for patients with anorexia nervosa (AN).
The dearth of evidence and lack of consensus amongst dieti-
tians may result in inconsistent treatment approaches [12],
with patients potentially receiving counselling and education
that is not appropriate for their treatment needs. The impli-
cation of this is other clinicians often do not have a clear
understanding of the role of a dietitian as part of a patient’s
treating team and how their input could assist patients to
achieve recovery from an ED. They may also avoid involve-
ment of a dietitian because of the variability in quality of
dietetic intervention, with perceived risk of exposure to a
treatment that may be detrimental to the patient’s condition
[15].
A second barrier relates to general practitioners involving
dietitians in patient care. Research has shown that they may
not make a referral due to the perception that the patient may
not (1) benefit from dietetic input [16], (2) implement nutri-
tional recommendations [16], or (3) be interested in dietetic
treatment [17] as well as (4) the financial cost to patient and
long waiting lists to access dietetic treatment [17].
In the presence of these barriers to access and delivery of
appropriate dietetic intervention as part of ED treatment, the
nutrition and food-related content of available ED treatment
manuals is commonly applied in clinical practice by mental
health professionals. To date, the nutrition and food-related
content of these treatment manuals for EDs has not been
extracted and reviewed. Therefore, this review aims to assess
the degree to which recommendations from guidelines and
the literature have been incorporated in these manuals by
(1) summarising the nutrition and food-related content of
treatment manuals designed for adults with an ED, and (2)
evaluating the degree with which this information conforms
with current recommendations.
Methods
Identification of treatment manuals
Inclusion criteria
Manuals were included in the review if they were written by
a clinician or researcher, designed for use with individual
13
adult patients, published after 1990, written in English and
available in hard copy. Manuals were excluded if they were
available only as electronic or audio books which required
payment to access, were self-help or guided self-help treat-
ments, were only very brief descriptions of psychologi-
cal approaches rather than detailed protocols, written by a
patient or carer, or if a copy could not be obtained due to
being out of print.
Search and screening strategy
Treatment manuals for adults with an ED were identified
by conducting an online search in March 2018 of Internet
book dealer Amazon and University of Sydney library cata-
logue. Searches were conducted using the following key-
words: “anorexia nervosa”; “bulimia nervosa”; “binge eat-
ing disorder” and “eating disorder”. This search strategy is
consistent with methods used in other reviews examining
self-help patient resources [18, 19]. Snowballing and hand
searches were also used to identify additional manuals not
captured in these searches. Books were first screened by title
and description of the book and were included in full text
screening if they appeared to meet the inclusion criteria,
or where uncertainty arose. Full texts were then retrieved
and assessed for fulfilment of inclusion criteria. If multiple
editions of a manual existed, the most recent was selected,
and for treatments described in multiple publications, the
most detailed version was used. Where required, authors
were contacted to obtain the most detailed and up to date
versions of manuals.
Extraction and review of nutrition and food‑related
content
The nutrition and food-related content of each manual was
extracted independently by two authors (C.M. and S.H.).
The review of any nutrition and food-related content con-
tained in each manual was guided by criteria based on cur-
rent best evidence to date on dietetic treatment for patients
with EDs, as detailed in Table 1. Each manual was reviewed
for content regarding the following: (1) nutrition education
topics; (2) food and eating skills; (3) nutritional assessment;
(4) monitoring of nutritional status; (5) use of a dietitian as
a co-author of the manual or of nutrition and food-related
content; (6) citation of literature to substantiate nutrition and
food-related information and recommendations; (7) nutri-
tion information inconsistent with current evidence; and (8)
recommendation to collaborate with a dietitian as part of
multidisciplinary treatment. The complete criteria are pro-
vided in Table 2. The two authors’ reviews were compared to
identify any discrepancies and resolve these collaboratively.
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
Table 1  Current recommendations regarding dietetic intervention in the treatment of eating ­disordersa
Source
Academy of Eating Disorders
[7]
American Dietetic Associa-
tion [2]
Dietitians Association of
Australia [3]
National Institute for Health
and Care Excellence [6]
Royal Australian and New
Zealand College of Psychia-
trists [5]
49
Recommendations
Multidisciplinary team approach (medical, psychological and nutritional) is the ideal standard of care
Assessment should consider quantity and variety of dietary intake and restriction of specific foods or food
groups such as fats and carbohydrates
Goals of nutritional management should include:
Weight restoration
Restoration of meal patterns that promote health and social connections
Management of refeeding and its potential complications
Nutritional assessment: identify nutrition problems that relate to medical or physical condition, including ED
symptoms and behaviours
Nutrition intervention:
Calculate and monitor energy and macronutrient intake to establish expected rates of weight change and to
meet body composition and health goals
Guide goal setting to normalize eating patterns for nutrition rehabilitation and weight restoration or mainte-
nance
Nutrition monitoring and evaluation: monitor nutrient intake and adjust as necessary
Care coordination: provide counsel to team about protocols to maximize tolerance of nutrition recommenda-
tions, guide supplement use and minimize drug nutrient interactions
Nutritional management of AN should always be provided in collaboration with medical and psychological
therapies
Nutritional assessment and diet history should be taken to identify:
BMI
Weight history
Abnormal eating behaviours
Attitude to weight loss
Relationships between the patient’s emotions and food
Nutritional interventions for AN should increase energy intake from a nutritionally balanced diet to:
Optimise nutritional status
Restore body weight, body composition and biochemistry to a normal range
Nutritional interventions for AN should include education about:
Medical, physical and psychological consequences of excessive dieting and weight loss behaviours
Weight gain
Changes to metabolism
Culturally appropriate eating behaviour
For patients with AN:
Provide psychoeducation and nutritional education and advice
Encourage healthy eating and reaching a healthy body weight
Encourage patients to take an age-appropriate oral multivitamin and multi-mineral supplement until their diet
includes enough to meet their dietary reference values
Only offer dietary counselling as part of a multidisciplinary approach
For patients with BN: establish a pattern of regular eating
For patients with BED:
Eat regular meals and snacks to avoid feeling hungry
Include weekly monitoring of binge eating behaviours, dietary intake and weight
Multidisciplinary approach to treatment including access to combined medical, dietetic and psychological
interventions
For patients with AN:
Assessment should consider disturbed eating behaviours (e.g., eating apart from others, ritualistic patterns of
eating) and nutritional and fluid intake, including adequacy of main meals and snacks
Nutritional counselling alone should not be the sole treatment
13
50 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60

Table 1  (continued)
Source Recommendations

Key literature on nutrition Nutritional assessment should consider assessment of:

and dietetic practice [1, 4, Excess intake (e.g. alcohol, supplements, convenience foods)
10–14]
Insufficient intake (e.g. specific nutrients or food groups, lack of interest in food)
Intake different from recommended (e.g. inappropriate use or choice of food, inappropriate medication or sup-
plement use)
Food and nutrient intolerance
Nutrition and health awareness (e.g. disordered beliefs about the effect of specific foods or nutrients)
Food and nutrient knowledge and skills (e.g. inability to apply food and nutrition information to change behav-
iour, lack of ability to prepare meals)
Physical activity
Food availability
Medications and supplements
Nutrition intervention should include:
Meal planning
Nutrition education (e.g., metabolism, nutrition misinformation, nutritional requirements, calcium intake)
Psychoeducation (e.g., effects of starvation, consequences of binge eating and compensatory behaviours, food
avoidance)
Advice on normal eating (e.g., avoid diet products, use of appropriate utensils, avoid measuring or weighing
food)
Advice on stopping weight losing behaviours
Nutrition counselling including engagement, motivational strategies and collaboration
Behavioural strategies such as goal setting, food exposure hierarchy and self-monitoring
Practical and social eating skills (e.g. practice eating out, advice on shopping, cooking and meal preparation)
Nutrition intervention should target the following dietary issues:
Adequate intake of ‘core’ food groups i.e., carbohydrate, protein, fruits, vegetables, calcium-rich foods and
fluid
Adequate intake of dietary fat, fat-soluble vitamins and essential fatty acids
Adequate intake of calcium intake to support bone health
Limit diet foods (e.g. diet soft drinks, low fat products) and ‘fillers’ such as excessive consumption of caffein-
ated beverages
Exposure to avoided foods and food groups
a
AN anorexia nervosa, BED binge eating disorder, BMI body mass index, BN bulimia nervosa, ED eating disorder

Results
Of the 10,890 books screened, 10,849 were excluded based
on their title and description (Fig. 1). Forty-one books were
assessed for eligibility and 22 of these met eligibility crite-
ria—three manuals for adjunctive treatments and 19 manuals
for standalone treatments.
Characteristics of treatment manuals
Details of included treatment manuals are summarized in
Table 3. Manuals were published between 1997 and 2015
and included the following: eight manuals for patients
with bulimia nervosa (BN) or binge eating disorder (BED)
[20–26]; four manuals for patients with AN [27–30]; three
manuals for patients with either AN or BN [31–33]; three
manuals for patients with either AN, BN or BED [34–36];
three manuals for patients with BN [37–39]; and two manu-
als for patients with BED [40, 41].
Extraction and review of nutrition and food‑related
content
Frequency of included components as per the criteria used to
review the nutrition and food-related content of the treatment
manuals is shown in Fig. 2. Two treatment manuals (9%) did
not include any nutrition and food-related content [25, 27].
Nutrition education
Sixteen manuals [20–22, 26, 28–31, 34–41] (73%) included
some degree of nutrition education content. The Waller
et al. [36] and Gilbert [35] manuals contained extensive
and detailed nutrition education content, including meal

13
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60 51

Table 2  Criteria developed using current best evidence to date to review nutrition and food-related content of included treatment manuals

1. Nutrition education topics Inclusion of the following nutrition education topics:

2. Food and eating skills
3. Nutritional assessment
4. Monitoring of nutritional status
5. Inclusion of dietitian as a co-author
6. Citation of dietetic literature
7. Inclusion of nutrition information inconsistent Includes nutrition and food-related information inconsistent with current best evidence to
with current evidence
8. Recommendation to collaborate with a dietitian Includes recommendation to consult with or refer to a dietitian as part of a multidisciplinary
Regular eating and related physiological changes
Core food groups, nutritional adequacy and choosing a variety of foods
Side effects of an eating disorder
Importance of including feared foods
Bone health
Metabolism
Dietary myths
Fluid intake
Dietary supplements
Feedback on food/behaviour monitoring
Dental health
Alcohol
Vegetarianism/veganism
Inclusion of the following food and eating skills:
Goal setting
Food/behaviour monitoring
Meal planning
Addressing barriers to meal plan compliance
Practical skills (e.g. grocery shopping, meal preparation)
Mindful eating and identifying hunger/fullness
Social eating and food challenges
Reducing calorie counting
Includes recommendation for nutritional assessment to be included in patient’s treatment—
yes/no
Includes recommendations for nutritional status to be monitored during patients’ treatment
(e.g., monitoring of weight, biochemistry, dietary intake)—yes/no
Dietitian is included as a co-author of the treatment manual or nutrition and food-related
content in the manual—yes/no
Includes citation of literature to substantiate nutrition and food-related information and
recommendations—yes/no
date—yes/no
approach to treatment—yes/no

plans, guidance on portion sizes and provision of evidence
supporting the nutritional adequacy of this information.
Fourteen manuals [20–22, 26, 28–31, 34, 37–41] included
less detailed nutrition education content, e.g., reference to
population-wide dietary guidelines, recommendation to con-
sume a varied diet. The most commonly included nutrition
education topics included the following: regular eating and
related physiological changes (n = 15, 68%); side effects of
EDs (n = 14, 64%); core food groups, nutrition adequacy and
choosing a variety of foods (n = 7, 32%); and bone health
(n = 7, 32%) (Fig. 2).
Food and eating skills
Nineteen manuals [20–24, 26, 28–31, 33–41] (86%) included
at least one food and eating skill. McIntosh et al. [28]
contained the highest number of skills (six): goal setting;
food and behaviour monitoring; meal planning; address-
ing barriers to meal plan compliance; practical skills (e.g.,
grocery shopping); social eating and food challenges. The
most commonly included food and eating skills across all
treatment manuals were: goal setting (n = 16, 73%); food
and behaviour monitoring (n = 14, 64%); and meal planning
(n = 9, 41%) (Fig. 2).
Nutritional assessment and monitoring
Nine manuals [26, 28–32, 34–36] (41%) recommended regu-
lar weighing to assess progress and as a proxy to monitoring
improvements in dietary intake. The McIntosh et al. [28]
manual was the only one to include guidance on what should
be considered as part of a nutritional assessment. Waller

13
52
Identification
Books identified
(n = 10886)
Manuals identified through other sources
(n = 4)
Books screened by title and
Screening
description
(n = 10890)
Eligibility
Books assessed for
eligibility
(n = 41)
Included
Manuals included for review of
nutrition content and consistency
with dietetic evidence
(n = 22)
Fig. 1  PRISMA flow diagram of treatment manual search and selec-
tion process
et al. [36] and McIntosh et al. [28] also made reference to
the importance of more comprehensive monitoring of nutri-
tional status such as reviewing dietary intake, weight status
and biochemistry.
Authorship and citation of literature
Of the 22 manuals reviewed, two [20, 36] (9%) included a
dietitian as a co-author and six [20, 29, 34–36, 39] (27%)
cited dietetic literature.
Nutrition information inconsistent with current evidence
Thirteen manuals [20, 21, 23, 26, 30, 32, 34–36, 38–41]
(60%) were assessed as providing nutritional information
or advice not substantiated by current literature. A summary
of nutritional recommendations that are inconsistent with
evidence, along with the current evidence, is presented in
Table 4. Such recommendations included food choices not
consistent with current descriptions of dietetic practice (e.g.,
fat modified dairy products for patients with AN or BN) or
dietary advice for which no research currently exists (e.g.,
use of low glycaemic index carbohydrates to prevent binge
eating). Although nutritional information or advice not sub-
stantiated by current literature may be based on authors’
expert opinion and clinical experience, no indications of this
were made in any of the manuals.
Involvement of dietitians in treatment
Eight manuals [26, 28, 29, 31, 34–36, 40] (36%) recom-
mended that a dietitian be consulted or referred to as part
13
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
Books excluded
(n =10849)
Books excluded
(n = 19)
Supplemented by a more
detailed treatment manual = 4
Self-help treatment = 1
Treatment not specific to
patients with an eating
disorder = 2
Not manualized treatment = 11
Unable to locate = 1
of the multi-disciplinary management of patients. Of these
eight, four [34–36, 40] included criteria for when this would
be indicated.
Discussion
This review aimed to assess the degree to which recom-
mendations from guidelines and the literature have been
incorporated into current treatment manuals by summaris-
ing the manuals’ nutrition and food-related and evaluating
the degree to which this information conforms with current
recommendations. Overall, the nutrition and food-related
content of reviewed manuals varied from no information on
food and nutrition [25, 27] through to the provision of very
detailed information [35, 36]. Practice guidelines for ED
treatment emphasise the importance of holistic care, which
encompasses psychological, nutritional and medical inter-
vention [5]. Hence, it is encouraging that some authors have
included information on food and nutrition, but two major
shortcomings in the nutrition and food-related content of the
manuals were identified.
First, nine of the 22 manuals (41%) recommended regu-
lar weighing to assess progress, including as a proxy for
improvements in dietary intake. Relying on monitoring of
weight alone can fail to detect malnutrition—a serious medi-
cal condition that can be present in any patient engaging
in disordered eating behaviours, regardless of weight status
[7]. Waller et al. [36] and McIntosh et al. [28] were the only
manuals to make reference to the appropriate monitoring of
nutritional status i.e., by reviewing dietary intake, weight
status and biochemistry together, without specifying con-
sultation with a dietitian.
Second, 14 manuals (64%) did not cite any dietetic litera-
ture to substantiate the nutrition and food-related content in
their treatment. For example, existing research on nutritional
issues in EDs such as use of vegetarian and vegan diets [10,
66, 67], dietary supplements [14, 68–70] and the importance
of adequate calcium intake [10, 11, 66, 71] was not cited.
Some manuals [28, 36, 39] made reference to evidence-
based nutrition education resources such as MyPlate [72]
or the Eatwell Guide [73]. However, these are nutrition edu-
cation guides for the broader community and designed for
the prevention of an overweight population and reduction of
diet-related and chronic diseases [10]. Messages contained
in these guides such as choosing low-fat dairy products, lim-
iting fats and oils and increasing fruit and vegetable intake
are not appropriate nutritional targets for ED patients and
may reinforce patients’ dietary rules and eating disorder
cognitions [10].
Across the manuals, there was limited citation of
appropriate, published peer-reviewed literature and low
involvement of dietitians in the authorship of nutrition and
 Table 3  Summary of treatment manuals reviewed for food and nutrition-related ­contenta
Title
Adjunctive treatments Appetite-focused CBT for binge eating [20]
A clinician’s guide to getting better bit(e) by bit(e): a
survival kit for sufferers of BN and BED [21]
Cognitive remediation therapy for AN [27]
Standalone treatments Bulimia/anorexia: the binge-purge cycle and self- 2001
starvation [31]
Treating BN and binge eating: an integrated metacogni- 2009
tive and cognitive therapy manual [22]
CBT and EDs [34]
Therapy for EDs: theory, research and practice [35]
A systematic treatment of BN: women in transition [37] 2001
Beyond a shadow of a diet: the comprehensive guide
to treating BED, compulsive eating and emotional
overeating [40]
Specialist supportive care therapist manual [28]
BED: clinical foundations and treatment [41]
Prison of food: research and treatment of EDs [32]
13
Year Target diagnosis Description of treatment
2007 BN, BED Aims to eliminate binge eating by re-training patient to respond to internal
appetite cues
1997 BN, BED Guide to how chapters in Bit(e) by Bit(e) [42] can be used to ameliorate
various aspects of bulimics’ difficulties
Emphasis on motivating patients who are reluctant to change their behav-
iour, using a motivation interviewing approach
2010 AN Involves mental exercises aimed at improving cognitive strategies, thinking
skills and information processing through practice
Promotes reflection on thinking styles, encourages thinking about thinking
and helps to explore new thinking strategies in everyday life
AN, BN Treatment program involving individual psychotherapy and concurrent
group treatment on a weekly basis
BN, BED Addresses patients’ uncertainty and anxiety about changing eating and
behaviours
Teaches strategies and techniques to reduce binge eating such as question-
ing negative and positive beliefs about eating, and challenging unhelpful
behaviours
2008 AN, BN, BED Focus on processes that are maintaining a patient’s psychopathology, with
cognitive processes being viewed as of paramount importance
Uses cognitive and behavioural strategies and procedures, integrated with
relevant education
2014 AN, BN, BED Aims to teach patients about how EDs are triggered and maintained and
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
about the links between deprivation and mood
BN Aims to address the major aspects of systems that can cause and maintain
BN (behavioural, interpersonal, developmental and sociocultural)
2014 BED Aims to teach clinicians to help their patients end binge, compulsive or emo-
tional overeating and how to cure their eating problems to pave the way for
physical, emotional and spiritual wellbeing
1997 AN Combines features of clinical management and supportive psychotherapy
Aims to assist patients establish healthy eating and a healthy weight through
education and advice about AN and nutrition, and support and encourage-
ment in implementing this advice and making changes
2008 BED Aims to: interrupt binge eating behaviour; reinstitute more normal eating
habits; change erroneous beliefs about weight and shape and develop
healthier attitudes towards one’s body
2005 AN, BN, purging disorder Involves components of systemic family therapy, suggestive manoeuvres and
stratagems that lead to unconscious changes and cognitive explanations of
the process of treatment
53
 54

Table 3  (continued)
Title Year Target diagnosis Description of treatment

13
CBT for AN [29]
DBT for binge eating and bulimia [23]
Acceptance and commitment therapy for EDs: a
process-focused guide to treating anorexia and
bulimia [33]
The Maudsley Model of AN Treatment for Adults
(MANTRA) [30]
IPT for EDs [24]
Coping strategies therapy for BN [38]
CBT for EDs: a comprehensive treatment guide [36]
Integrative cognitive-affective therapy for BN: a treat-
ment manual [39]
Psychodynamic therapy for EDs [25]
Treatment plans and interventions for bulimia and BED 2012 BN, BED
[26]
a
AN anorexia nervosa, BN bulimia nervosa, BED binge eating disorder, CBT cognitive behaviour therapy, DBT dialectical behaviour therapy, ED eating disorder, EDNOS eating disorder not oth-
erwise specified, IPT interpersonal psychotherapy
2012 AN Based on a CBT model that views overvalued ideas about control over eat-
ing, shape and weight as the core maintaining mechanism in AN
Includes schema-based approach that addresses issues beyond eating and
weight
2009 BN, BED Aims to stop problematic eating behaviours (e.g., binge eating, binge/purge
episodes)
Includes skills training which focuses on learning and practicing adaptive
emotion regulation skills to replace maladaptive problematic eating behav-
iours, including mindful eating
2011 AN, BN Targets psychological flexibility, defined as actively and openly contacting
ongoing experiences in the present moment as a fully conscious human
being, without defence and as it serves one’s chosen values
2014 AN Biologically informed, cognitive interpersonal treatment for AN incorporat-
ing neuroimaging, neuropsychological, social cognitive and personality
trait research in AN
2012 BN, BED Aims to improve interpersonal functioning and self-esteem, reduce negative
affect and in turn decrease ED symptoms
2000 BN Conceptualises treatment in terms of coping skills training using aspects of
CBT, IPT and DBT
2007 AN, BN, BED Focussed around techniques designed to help patients challenge beliefs that
drive eating behaviours
Includes skills generic to work in EDs (assessment, motivation, dietary and
nutritional knowledge, case formulation, therapy interfering behaviours,
homework) and skills specific to CBT as applied to EDs (agenda setting,
psychoeducation, diary keeping, weighing, therapeutic relationship)
2015 BN Emotion-focused treatment that emphasizes the functional relationship
between emotional states and bulimic behaviour alongside elements of
traditional behavioural therapy (self-monitoring, planned meals, direct
efforts to modify behaviour)
2012 BN, BED Aims to explore and rectify interpersonal and intrapsychic issues of the
patient in the relationship with the therapist toward attenuation of the
patient’s self-destructive symptoms patterns, and to significantly improve
quality of life
Guide for providing CBT for BN as well as adapting treatment for BED,
purging disorder, subthreshold BN and other variations of EDNOS
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60 55

Fig. 2  Proportion of treatment Regular eating and related physiological changes

manuals (%) which included
the following: (1) evidence- Core food groups, nutrition adequacy and choosing a variety of foods
based nutrition education topics Side effects of an eating disorder
and food and eating skills; (2)
Importance of including feared foods
recommendation to include
nutritional assessment and Bone health
monitoring of nutritional status;
Metabolism
(3) dietitian as a co-author; (4)
nutrition and food-related con- Dietary myths
tent inconsistent with current Fluid intake
evidence; (5) recommendation
to collaborate with a dietitian Dietary supplements

Feedback on food/behaviour monitoring

Dental health

Alcohol

Vegetarianism

Goal setting

Food/behaviour monitoring

Meal planning

Addressing barriers to meal plan compliance

Practical skills (e.g., grocery shopping, meal preparation)

Mindful eating and identifying hunger/fullness

Social eating and food challenges

Reducing calorie counting

Recommendation to include nutritional assessment

Recommendation to monitor nutritional status

Inclusion of dietitian as co-author

Citation of dietetic literature

Inclusion of information inconsistent with current evidence

Recommendation to collaborate with dietitian

0 20 40 60 80 100
% Treatment manuals including component

food-related content. This is likely to have contributed to
nutrition information inconsistent with current evidence
being identified in 60% of the manuals reviewed. Nutri-
tional information based on personal approaches rather than
evidence-based information may result in patients receiv-
ing education and advice that is not appropriate for their
treatment needs [12] and has the potential to play a role in
protracted course of illness experienced by some ED patients
[74].
Just over one-third (36%) of manuals reviewed recom-
mended a dietitian be consulted or referred to as part of a
patients’ treatment as recommended by current guidelines
[2, 3, 5–7] and peer-reviewed publications [1, 4, 10–14].
Six [26, 28, 29, 34–36] of the eight manuals recommended
as a first-line treatment for EDs by the National Institute
for Health and Care Excellence [6] (i.e. cognitive behav-
ioural therapy, specialist supportive care, Maudsley Model
of Anorexia Nervosa Treatment for Adults and interpersonal
psychotherapy) recommended that clinicians consult with
a dietitian.
Implications for practice and research
While some of the most commonly included nutrition edu-
cation topics, and food and eating skills (regular eating and
related physiological changes, side effects of EDs, goal set-
ting, food and behaviour monitoring) are components of
treatment that are able to be delivered by any clinician, other
practical skills (e.g., addressing barriers to meal plan com-
pliance; choosing recipes, grocery shopping, meal prepara-
tion, and social eating and food challenges) were included
less frequently in the manuals. It is these skills which may
more appropriately sit within the scope of dietetic prac-
tice. There is, however, an overall lack of clarity regard-
ing what information and advice can be delivered by non-
dietitians and what is specific to dietitians. Unclear division

13
 56

Table 4  Summary of nutritional information in reviewed treatment manuals inconsistent with current ­evidencea
Nutritional recommendation Current evidence

13
1. Weight changes For patients with BN, they can be reassured that they will rarely put on Treatments that target changes in eating patterns are likely to lead to fluctua-
weight during treatment if they eat meals and snacks [34, 38] tions and/or changes in weight, including weight gain for BN [43] and BED
[44]
Some patients may gain weight when they begin to eat regularly, particularly
those whose BMI falls between 20 and 25 but who are weight suppressed
[43]
2. Portion sizes Subjective and vague advice given to patients on determining portion sizes, Education on appropriate portion sizes should be delivered by a dietitian based
e.g. “average-sized portions of food” [34]; "normal" portions [26]; deter- on patients’ nutritional needs [2, 10]
mine portions size by mimicking others [34, 35] Describing portions as “average” and “normal” is subjective and cannot be
easily quantified by patients with an ED [45]
Modelling eating off others may reinforce disordered eating beliefs and
behaviours as food choices of peers may reflect different nutritional require-
ments and eating patterns to those recommended for patients with an ED
[10, 46, 47]
3. Guidance on food choices Patient given sole responsibility of making dietary choices [32, 40] or Patients should receive guidance about food choices during treatment [2]
directed to general nutrition guidelines such as MyPlate [39] Patients with an ED often have poor knowledge of wider nutritional issues
[48, 49]
General guidelines such as MyPlate are not tailored to nutritional needs of
patients with an ED and may reinforce dietary rules and eating disorder
cognitions [10]
4. Specific food advice Patients should choose skim or low-fat dairy products [21, 32, 36, 39] Most patients with an ED require standard dairy products due to low intake of
a. Dairy products fat-soluble vitamins [50–53, 67] and deficiencies of essential fatty acids [10,
53, 54, 70]
Standard dairy products are recommended for underweight patients to meet
energy needs and assist with weight gain [10, 55]
b. Protein Patients should increase protein intake to assist in reducing binge eating [20, Inadequate research to support use of high-protein diets to manage binge eat-
35] ing in patients with an ED [56, 57]
c. Carbohydrate Patients should choose carbohydrates that have a more sustained release of No established benefits for choosing low GI foods over moderate-high GI
energy and last longer, i.e., lower GI and glycaemic load to promote satiety foods for patients with an ED, including managing binge eating
[20]
5. Nutritional requirements Option to calculate energy (calorie) needs if necessary [21, 30, 39] Discussion of calorie requirements not recommended as part of treatment with
patients with an ED [14] as it is likely to reinforce ED behaviours
6. Eating behaviours Assumption that disordered eating behaviours will resolve during treatment Disordered eating behaviours contribute to the maintenance of an ED and do
e.g. “the way patients eat does not need to be addressed unless slow and not always resolve with weight restoration [58]
ritualised eating seen in some patients who are underweight is obstructing
progress” [34]
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60 57

of responsibilities in clinical practice can lead to encroach-

gastric motility [63] which impacts on patients’ ability to accurately identify

by non-dietitians is not clearly defined, meaning some advice given by non-

Recommended that all ED therapists have sufficient basic nutritional knowl-
ment on colleagues’ scope of practice, undermining of col-

dietitian if necessary [64]. However, the detail of what should be provided

Use of mindful eating may not be appropriate for all patients and should be

edge to be able to identify distortions in their patients and refer them to a

abnormalities in appetite hormones [60], gastric emptying [61, 62] and
leagues’ clinical input, clashing of treatment approaches and

Gastrointestinal physiology of individuals with BN and BED has shown

strategies and poor communication [65], all of which have
the potential to impact adversely upon patient outcomes.
To facilitate a more collaborative approach to treatment for
applied with caution in the early stages of treatment [59]

EDs, there is a need for consensus amongst dietitians and

non-dietitian clinicians regarding the roles of each member
of a patient’s treating team, including what responsibilities

dietitians may be outside scope of practice [65]

hunger/fullness and use this to regulate intake

are shared between the disciplines and what responsibilities

are discipline-specific.
This review also highlights the need for dietitians to: (1)
document and disseminate their approaches to dietetic man-
agement of patients with an ED, and (2) undertake research
regarding the effectiveness of dietetic treatment on clinical
outcomes such as patients’ weight, nutritional status and ED
severity. The current lack of dissemination and empirical
AN anorexia nervosa, BED binge eating disorder, BN bulimia nervosa, BMI body mass index, ED eating disorder, GI glycaemic index

testing of evidence-based information on food and nutri-

Current evidence

tion means non-dietitian clinicians often do not have a clear

understanding of the dietitian’s role in treatment and how
their input could assist patients to achieve recovery from
an ED. For example, in a survey by the Academy of Eating
Disorders, ED clinicians were asked to rate the most impor-
labels, consuming adequate amounts of vegetables, fruits and fibre, mini-
8. Delivery of nutrition education Therapists should deliver “basic” nutritional education, e.g., checking food

tant features of a high quality ED service [75]. Only 6.3%

Patients with BN and BED should utilise mindful eating to reduce binge

of American and 3.4% of United Kingdom (UK) respond-

ents listed “nutritional assistance” [75]. Similarly, in a sur-
vey conducted by the UK’s Royal College of Psychiatrists
regarding perceptions of the strengths of the ED service in
mizing consumption of saturated fats and trans fats [41]

which they worked, only two of the 113 respondents viewed

input from a dietitian/nutritional support as a strength of
their service [76]. In contrast to this, American ED consum-
ers and carers ranked “nutritional assistance” as the most
and fourth most important aspect of a high quality ED ser-
vice respectively [75].
It is recommended that future studies involve investiga-
tion of the effectiveness of dietetic approaches such as those
documented by Hart et al. [10], Herrin, Larkin [11], Laessle
et al. [77] and Setnick [1] delivered alongside evidence-based
eating [23, 26, 40]

psychological interventions. Research in this area will assist

in the understanding of the role of dietetic intervention in
the treatment EDs, contribute to the evidence base underpin-
ning treatment recommendations for adults with an ED and
improve training opportunities for clinicians in the ED field.
Finally, it is imperative that ED treatment manuals reflect
current practice guidelines and peer-reviewed literature. To
enhance ED treatment manuals, it is recommended that
Nutritional recommendation

authors make reference to the importance of a multidisci-

plinary approach to treatment, including when it may be
Table 4  (continued)

appropriate for clinicians to refer to a dietitian. For manuals

7. Mindful eating

that include nutrition and food-related content, it is recom-

mended that authors consult with a dietitian wherever pos-
sible, and ensure this content is consistent with published,
peer-reviewed literature and relevant evidence is cited.
a

13
58 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2021) 26:47–60
Limitations
This review only considered treatment manuals published
after 1990 and those designed for use with patients indi-
vidually i.e., did not consider the nutrition and food-related
content of manuals for self-help, online or group ED inter-
ventions. Second, the review process did not involve analysis
by a dietitian from outside the field of EDs or a non-dietitian
clinician working in EDs. The addition of a third reviewer
would have assisted in reducing any bias which may be pre-
sent as a result of having two ED specialist dietitians review
manuals.
What is already known on this subject?
Clinical practice guidelines recommend dietetic assessment,
education and intervention as part of the multidisciplinary
treatment of adults with EDs. The current dearth of literature
and lack of consensus amongst dietitians to guide the content
of dietetic intervention mean nutrition and food-related con-
tent of available ED treatment manuals is commonly applied
in clinical practice by mental health care professionals.
What this study adds?
This review demonstrates that the majority of ED treatment
manuals do not endorse the inclusion of a dietitian as part
of a multi-disciplinary treatment approach and contain a
varying degree of nutrition and food-related content, some
of which is inconsistent with current evidence. Greater
collaboration between dietitians and clinicians is required
to develop, evaluate and disseminate evidence-based
approaches to nutritional management.
Acknowledgements Caitlin M McMaster is a recipient of a Research
Training Program scholarship from the Australian Government,
Department of Education and Training.
Compliance with ethical standards
Conflict of interest No conflicts of interest to declare.
Ethical approval This article does not contain any studies with human
participants performed by the authors.
Informed consent This type of study does not require any formal con-
sent.
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