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ANZAED practice and training standards fordietitians providing eating disordertreatmentGabriella Heruc1,2,3* , Susan Hart4,5, Garalynne Stiles6, Kate Fleming7, Anjanette Casey8, Fiona Sutherland1,9,Shane Jeffrey1,10,11, Michelle Roberton12 and Kim Hurst1,13,14

Abstract

Introduction: Dietitians involved in eating disorder treatment are viewed as important members of the multidisciplinaryteam. However, the skills and knowledge that they require are not well characterised. Therefore, as part of a broader projectto identify the key principles and clinical practice and training standards for mental health professionals and dietitiansproviding eating disorder treatment, the Australia & New Zealand Academy for Eating Disorders (ANZAED) sought to identifythe key practice and training standards specific to dietitians. An expert working group of dietitians was convened to draftthe initial dietetic standards. After expert review, feedback on the revised standards was then provided by 100 healthprofessionals working within the eating disorder sector. This was collated into a revised version made available online forpublic 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 generalprinciples and clinical practice standards for mental health professionals and dietitians. In addition, they should also becompetent in the present eating disorder-specific standards based around the core dietetic skills of screening, professionalresponsibility, assessment, nutrition diagnosis, intervention, monitoring and evaluation.

Conclusions: These standards provide guidance on the expectations of dietetic management to ensure the safe andeffective treatment of individuals with an eating disorder. Implications for professional development content and trainingproviders 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.

Keywords: Dietetic, Dietitian, Eating disorder, Nutrition, Practice standards, Training, Treatment

Plain English summaryDietitians play an important role in eating disorder treat-ment, however the skills and knowledge they require toprovide safe and effective treatment is not well defined.This paper aimed to describe the clinical practice andtraining standards for dietitians providing eating dis-order treatment. The Australia & New Zealand Academy

for Eating Disorders undertook extensive consultation toestablish agreement around what constitutes best diet-etic practice in the treatment of individuals with an eat-ing disorder. The resulting standards were based aroundthe core dietetic skills of screening, professional respon-sibility, assessment, nutrition diagnosis, intervention,monitoring and evaluation, and also outlined the expec-tations for training and supervision.

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* Correspondence: g.heruc@westernsydney.edu.au1Executive Committee, Australia & New Zealand Academy for EatingDisorders, Sydney, Australia2School of Medicine, Western Sydney University, Campbelltown, AustraliaFull list of author information is available at the end of the article

Heruc et al. Journal of Eating Disorders (2020) 8:77 https://doi.org/10.1186/s40337-020-00334-z

IntroductionThe role of the dietitian in providing eating disorder treat-ment as part of the multidisciplinary team has been widelyrecognised [1–3]. Dietitians play a pivotal role in helpingindividuals with eating disorders and their families under-stand the interaction between food, nutrition and well-being, as well as supporting eating behaviours that alignwith their treatment and recovery goals. Eating disordershave high morbidity and mortality rates [4], and failure toprovide early intervention is associated with a longer dur-ation and severity of illness, serious physical health conse-quences and a higher risk of mortality including risk ofsuicide [5]. However, morbidity and mortality in individ-uals with an eating disorder can be improved with effect-ive treatment [5]. Nutritional care contributes toimproving quality of life and morbidity and mortality ratesin general dietetics [6], but the dietitian’s role in eatingdisorder treatment is less clear and the specifics of dieteticpractice are not well defined [7].Although current clinical practice guidelines recom-

mend dietetic assessment, education and intervention aspart of the multidisciplinary treatment of eating disorders[1–3], there is a lack of detailed guidance for dietitians re-garding what outpatient dietetic treatment for eating dis-orders should encompass [8]. Moreover, there is anabsence of internationally accepted dietetic models of carewithin the eating disorders field, which may increase thelikelihood of inconsistent interventions [9] and limit clar-ity regarding the role of the dietitian, both within the diet-etic profession [10] and more broadly for other healthprofessionals [11]. Dietetic scope of practice in the treat-ment of eating disorders is diverse, but at a minimumshould include a tailored nutrition care process that: cor-rects nutritional deficiencies and promotes optimal nutri-tion status; addresses the role of eating and adequatenutrition in physical and mental well-being; and providesnutrition education to challenge inaccurate beliefs aboutfood [2, 7, 12, 13]. Having clearly defined practice stan-dards for dietitians will ensure effective, safe and timelycare for individuals with an eating disorder in addition toconsistent treatment approaches.The role of dietitians in eating disorder treatment also

appears to be affected by the adequacy of dietitian train-ing with dietitians feeling that dietetic training is inad-equate preparation for practice in eating disorders [14,15]. Communication and nutrition counselling in par-ticular are often insufficiently addressed at university,resulting in a gap in skillset for most dietitians [16, 17].Thus, dietitians providing eating disorder treatmentoften seek further clinical experience, post graduatetraining and professional supervision [14]. To supportethical and effective dietetic care in eating disorder treat-ment, clarification is required on the knowledge andskills that training programs need to address.

The current clinical practice and training standardsaim to describe the role of the dietitian in eating dis-order treatment and provide a roadmap for dietitians toprovide effective and safe care. This document builds onthe Australia & New Zealand Academy for Eating Disor-ders (ANZAED) general principles and practice andtrainings standards for all clinicians providing eating dis-order treatment concurrently published in the Journal ofEating Disorders [18]. Based around the core dieteticskills of screening, professional responsibility, assess-ment, nutrition diagnosis, intervention, monitoring andevaluation, it details the knowledge and skills that dieti-tians require to competently manage and treat individ-uals with an eating disorder. It also describes theexpectations and content required to be addressed intraining programs that provide education on the thera-peutic knowledge and skills outlined in these practicestandards. Consistent and standardised dietetic practicemay not only enhance the legitimacy and credibility ofdietitians as part of the multidisciplinary team, but mayalso lead to improvements in clinical care for individualswith eating disorders.

Methods of dietetic-specific practice and trainingstandards developmentANZAED established an expert working group of eightdietitians with representatives from Australia and NewZealand, each with between 12 and 30 years of clinicalexperience in eating disorder treatment. This was part ofa broader project to develop general clinical practice andtraining standards [18], as well as standards specific tomental health professionals [19] and dietitians providingeating disorder treatment.The working group initially developed draft dietetic-

specific standards based on published evidence and clin-ical experience, which were reviewed and refined byANZAED’s Executive Committee and expert advisors.As part of a combined clinical practice and trainingstandards document, the next draft version was thenpresented for public face-to-face consultation withoutanonymity at the ANZAED 2019 Conference inAdelaide, with feedback received and incorporated fromeating disorder professionals (n = 100). Following this,online consultation from the broader public was sought,with feedback received from international expert advi-sors, professional bodies (various disciplines) and con-sumer and carer groups with comments reviewed andintegrated by the working groups. The final version wasalso reviewed by the National Eating Disorder Collabor-ation Steering Committee and again by ANZAED’sExecutive Committee. Consensus was reached throughdiscussion by the authors and there was no identifiedconflict of interest. The resulting dietetic-specific clinicalpractice standards are detailed below and in Table 1.

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Table 1 Dietetic-specific clinical practice and training standards.The table below describes in detail the dietetic-specific practiceand training standards that were summarised in theRecommendations section. It outlines the specific practicepoints recommended that dietitians be taught, understand andutilise to ensure safe and effective eating disorder treatment

Table 1 (Continued)

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Table 1 (Continued) Table 1 (Continued)

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RecommendationsDietetic-specific clinical practice standardsIt is recommended that dietitians providing treatment toindividuals with an eating disorder follow the broadprinciples and practice standards outlined in TheAustralia & New Zealand Academy for Eating Disorderstreatment principles and general clinical practice andtraining standards for mental health professionals anddietitians [18]. In addition, to provide safe and effectivetreatment, it is recommended that dietitians treating in-dividuals with an eating disorder are also competent inthe dietetic-specific clinical practice standards sum-marised below and detailed in Table 1. General dieteticskills are assumed, in line with dietetic competencies setout by relevant dietetic registering bodies, and are notmentioned here.

ScreeningThe prevalence of eating disorder presentations in gen-eral dietetic practice remains unknown. However, all di-etitians have an important role in early identificationand the screening of high-risk individuals usingevidence-based tools, such as the SCOFF [20], andBEDS-7 [21]. For many individuals with an eating dis-order there are no, or few, obvious signs of ill-health.Without timely and appropriate screening and assess-ment, an opportunity for detection of symptoms may bemissed [22, 23].Individuals who should be screened for an eating

disorder may present to a dietitian to discuss theirdietary concerns without specifically seeking treatmentor support for an eating disorder. Individuals mightbelong to groups where there is a higher prevalenceof eating disorders, including those: (a) at higher [24]or lower body weights [25]; (b) with recent rapidweight loss or gain [26]; (c) presenting for weightmanagement with concomitant significant concernsabout appearance and/or repeated efforts to changebody shape (pursuing weight loss, or gain) [27]; (d)following a self-imposed (e.g. gluten-free, food allergy−/intolerance-related, vegan) [27, 28] or medicallyprescribed restrictive diet (e.g. due to type 1 diabetes,coeliac disease [29–31] or low ‘FODMAP’ diet due toirritable bowel syndrome [32]); (e) post-bariatric sur-gery [33]; (f) presenting with unspecified gastrointes-tinal symptoms such as constipation or abdominalpain [34, 35], or with a diagnosis of irritable bowelsyndrome [32]; (g) presenting with physical symptomsor electrolyte disturbance that could be attributed tostarvation/malnutrition or purging behaviour [36]; (h)being a restrained eater [37], or restricting energy andnutritional intake [38]; (i) having a concurrent mentalhealth concern [22, 39]; and (j) elite athletes who par-ticipate in individual sports or that require meeting a

weight criterion (e.g. lightweight rowers, jockeys, martialarts practitioners, boxers, dancers, gymnasts) [40].

Professional responsibilitiesConsistent recommendations are for dietetic interven-tion to be part of a multidisciplinary team interven-tion, and not an intervention to be delivered inisolation [2, 41].Clinicians in eating disorder practice are also advised

to have clinical supervision as a form of formal learningand reflective practice [18]. Although clinical supervi-sion is not historically utilised in the dietetics profes-sion [42], dietitians do highly value learning frommentors [14]. As seen in New Zealand [43], dietitianswould likely benefit from more formal clinical supervi-sion, with the aim of encouraging safe and competentpractice [42]. More specifically, dietitians working inthe mental health and eating disorders fields believethat supervision is required to help dietitians deal withchallenging behaviours and relationships [42, 44]. TheBritish Dietetic Association has introduced professionalsupervision to the dietetic profession, defining it as a“process of professional support and learning under-taken through a range of activities, which enables indi-viduals to develop knowledge and competence, assumeresponsibility for their own practice and enhanceservice-user protection, quality and safety of care” [45].Clinical dietetic supervision should use a model that issuited to the dietetics profession and learning style[46]. Clinical supervision has been reported by alliedhealth professionals to be most effective when profes-sional development was the focus of the supervision,the supervisor possessed the skills and attributes re-quired to facilitate a constructive supervisory relation-ship and the workplace provided an environment thatfacilitated this relationship and professional develop-ment [46]. Furthermore, since dietetics training oftendoes not have a strong counselling focus, it may be im-portant for the supervisee and supervisor to undergoformal training to ensure competency of supervisionskills [46].

Nutrition care processThe following has been developed in line with the Nutri-tion Care Process Terminology (NCPT) [47]. The pur-pose of NCPT is to provide an accurate and specificdescription of the services that nutrition and dieteticspractitioners deliver. The aim is to achieve a commonunderstanding of these services not only among nutri-tion and dietetics practitioners, but also outside the pro-fession, including individuals with an eating disorderand other members of the multidisciplinary team [48].Standardized terminology facilitates the clear descriptionof nutrition care through the following four steps of the

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Nutrition Care Process: nutrition assessment, nutritiondiagnosis, nutrition intervention, and nutrition monitor-ing and evaluation [49].

Nutrition assessment All dietitians are trained to under-take a nutrition assessment. However, when obtaining anassessment of an individual with an eating disorder (orsuspected eating disorder), additional questions and tailor-ing of the assessment is required. Factors across the as-sessment domains relevant to both physical and mentalhealth need to be considered. Particular attention shouldbe given to the individual’s beliefs about food, any dietaryrules, dieting behaviour, food avoidance, attempts to re-duce weight and weight history [2]. Additionally enquiringabout and being aware of physical and psychological signsand symptoms of starvation such as preoccupation withfood [50], hypothermia [50], bradycardia [51], posturalhypotension [51], GI dysfunction [34], appetite disturb-ance [52], social isolation [50], depression [53] andhypoglycaemia [54] is useful. Dietitians specialising in eat-ing disorder treatment should also ask about the fre-quency and triggers for eating disorder behaviours such asbinge eating, and compensatory behaviours such as vomit-ing, laxative use, and excessive exercise [2]. It is importantto be aware that eating disorders can occur in individualsof any age, gender or body size, cultural background anddemographic [55].

Nutrition diagnoses Dietitians working in the eatingdisorders field identify and manage specific nutritionproblems and diagnoses resulting from the psychologicaland physical complications associated with an eating dis-order (e.g. malnutrition) [2]. A nutrition diagnosis is dif-ferent from a medical/psychiatric diagnosis, and whileidentifying eating disorder signs and symptoms is ex-pected, providing a medical or psychiatric diagnosis isnot within the dietitian’s scope of practice.

Nutrition intervention The role of the dietitian is toidentify, plan and implement appropriate nutrition inter-ventions with the purpose of modifying nutrition-relatedhealth status, behaviours, knowledge and attitudes toachieve physical, psychological and nutritional recovery,as well as support behaviours and attitudes to best sus-tain an individual’s wellbeing [2]. This places thedietitian in an ideal role to contribute towards eatingdisorder recovery. A standardised nutrition interventionshould involve prioritising the goals and expected out-comes, the development of an appropriate nutrition planas required, establishment of interdisciplinary connec-tions and the implementation, documentation and revi-sion of the plan as required [2]. Wherever possible, thenutrition intervention should be collaboratively under-taken with the client.

Nutrition intervention planning. Eating disorderspresent both psychiatric and medical risk which needs tobe considered in planning nutrition interventions. Giventhe dietary rigidity present in eating disorders, dietitiansneed to consider how their interventions either supportor discourage eating flexibility and normalised eatingpatterns. In contrast to broad public healthy eatingguidelines, nutrition interventions should be designed tominimise exclusion of any foods including those consid-ered nutrient poor. Individuals with an eating disordergenerally experience high levels of anxiety about eating,which may affect the individual’s readiness for changeand tolerance of uncertainty. Dietitians need to tailortheir treatments to support individuals towards recoverywhile providing safe and ethical nutrition interventions[7, 56, 57].

Nutrition intervention implementation1. Food and nutrient delivery: Food and nutrient

delivery are tailored to the individual’s nutritionneeds, but the individual’s stage of recovery willhelp to inform the treatment plan. The treatmentplan considers evidence about specific foods andnutrients for weight restoration, appetite regulation,lifecycle nutrition, the presence of co-occurring psy-chiatric and medical conditions that affect nutri-tional status, and stage of recovery. In an inpatientsetting, dietitians may advise the multidisciplinaryteam on the most appropriate method of nutrientdelivery such as oral feeding, nutrition supplementsand/or nasogastric feeding [12, 57–59].

2. Nutrition education: Nutrition education isprovided throughout treatment and across alltreatment settings. This includes informationregarding energy and nutrient needs [60], the impactof food and nutrients on physical and psychologicalwellbeing, effects of energy or nutritional deficiency,appetite cues and the relationship between dietaryintake and exercise. Other topics that may berelevant for nutrition education include dietary ironand calcium requirements, family eating patterns,eating socially, shopping and cooking skills,metabolism and gastrointestinal function [59].Education should be directed towards the personwho is most responsible for making eating decisionsand this may be the individual, family, or carer and isdependent on the psychological treatment model[56]. Education serves to support the individual and/or family in considering the potential benefits ofincorporating sustainable change in eating patternsand behaviours to promote the recovery process. Thespecific timing and topics of education should beperson-centred, varying according to the stage ofchange.

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3. Nutrition counselling: Nutrition counselling isprovided to individuals and families, andcomplements the psychological model used intherapy. Nutrition and dietetic counselling practiceshave been identified and include but are not limitedto monitoring eating behaviour, beliefs and attitudesabout food and health, rationale for food choice,factors affecting eating behaviour and nutritionalstatus, factors affecting access to food, motivationand stages of change and addressing ambivalenceand barriers to behaviour change [61]. There shouldbe an awareness of the evidence-based psychologicalmodels used in eating disorder treatment (as out-lined by Hilbert et al. [62]). Understanding andcomplementing a psychological model with dieteticcare as part of the multidisciplinary team is differentfrom the dietitian implementing the model, andwhile understanding the principles of models ofcare for eating disorders is expected, implementinga psychological treatment model is not consideredto be within the dietitian’s scope of practice withoutsignificant additional mental health training andsupervision.

Coordination of nutrition care. Due to the high level ofmulti- and interdisciplinary care that occurs in eatingdisorder treatment, coordinating nutrition care be-tween professionals is particularly important. Eatingdisorder treatment necessarily includes traditionallydietetic tasks, such as weighing individuals and discuss-ing food and eating. Defining clear roles, boundariesand communication pathways between professionalsinvolved in care can help streamline effective care,minimise professional burnout and enhance client out-comes [44, 63].

Monitoring and evaluation Throughout treatment, on-going nutritional monitoring is required to evaluate out-comes of treatment and particularly change in eatingdisorder behaviour. Due to the focus on nutritional re-covery in eating disorder treatment, other members ofthe treatment team will also likely have a role in ongoingmonitoring and evaluation. It is important that treat-ment outcomes are evaluated both qualitatively (e.g.change in the individual’s perceived relationship withfood) and quantitatively (e.g. change in nutritional in-take). New and developing concerns need to be addressedwith the individual and communicated to the rest of thetreatment team as a lack of change in eating and eating dis-ordered behaviour may indicate a need to review treatment.

Dietetic-specific clinical training standardsDietetic-specific clinical training should either partiallyor entirely address the dietetic-specific clinical practice

standards outlined above and detailed in Table 1, de-pending on the duration and intensity of the trainingcourse. It is expected that training programs that edu-cate dietitians working with individuals with eating dis-orders should identify which of the standards theyaddress. The dietetic-specific clinical training standardsuse the NCPT. Currently, dietitians broadly agree thatuniversity training does not adequately prepare gradu-ates for providing eating disorder nutrition care andadditional training after graduation is often sought [10,14, 15]. Thus, after basic university dietetic training,training to achieve competency in these practice stan-dards may occur via multiple pathways, including formal(e.g. postgraduate coursework, workshops, conferences)and informal (e.g. reading, intuitive learning through ex-perience) learning opportunities [14]. Organisations andindividuals providing training in the dietetic manage-ment of eating disorders should be suitably qualified,recognised for their expertise in dietetic eating disordertreatment and have significant experience implementingeating disorder nutrition care.

Implementation and future directionsThis paper provides a comprehensive outline of the skillsand knowledge that a dietitian requires to provide effectiveand safe eating disorder treatment. It also describes thetraining and supervision required by dietitians, with thepractice standards forming the basis of the essential ele-ments of training. With the growing recognition that basicdietetic training at university does not adequately preparedietitians for working with individuals with eating disor-ders [10, 14, 15], these practice and training standardsmay guide the enhancement of undergraduate courseworkon the skills and knowledge necessary for such work andthe development of postgraduate learning pathways.The role and scope of practice of the dietitian pre-

sented also clarifies the skills and knowledge that thedietitian contributes to the multidisciplinary treatmentteam. It increases the understanding of how dieteticintervention assists individuals to achieve recovery froman eating disorder and ensures accurate nutrition adviceis delivered [11]. Furthermore, it builds an appreciationof the specialised perspective that each member of themultidisciplinary team brings to a coordinated treatmentplan, creating a continuum of cohesive care for the indi-vidual with an eating disorder.Documentation of the current practice and training

standards meet a long-standing need of the dietetic com-munity who deliver eating disorder treatment, detailingthe minimum skills and knowledge in which a dietitianshould be trained. However, a process for determiningcompetence to provide dietetic treatment in the eatingdisorder field has not yet been characterised. The futureincorporation of these practice standards into training

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processes and programs is an essential first-step to en-sure future dietitians can be adequately educated andsupported to work in the eating disorder field.

AcknowledgementsFor supporting and providing feedback on the development of the practicestandards, the authors would like to thank the ANZAED ExecutiveCommittee members: Kim Hurst (President), Sian McLean (President Elect),Mandy Goldstein (Secretary), Shane Jeffrey (Treasurer), Gabriella Heruc (PastPresident), Linsey Atkins, Kiera Buchanan, Shannon Calvert, Anthea Fursland,Deb Mitchison, Randall Long, Marion Roberts, Jessica Ryan and FionaSutherland. We also appreciate the guidance and advice received from theANZAED Past Presidents Committee: Phillipa Hay, Sloane Madden, SusanPaxton, Beth Shelton, Chris Thornton. We would also like to acknowledgethe additional expert advisors, Chris Basten and Claire Toohey, as well as allindividuals who provided feedback during the face-to-face and public onlineconsultation process. We are grateful for the input provided by the Dietitian’sAssociation of Australia, Occupational Therapy Australia, the Australian Psy-chological Society, the Royal Australia and New Zealand College of Psychia-trists, Eating Disorders Queensland (EDQ), Eating Disorders Families Australia(EDFA), the Butterfly Foundation and the ANZAED Consumer and CareerCommittee. We also offer our sincere thanks to the National Eating DisordersCollaboration Steering Committee for their comments and contributions.

Authors’ contributionsGH and KH co-chaired the working groups and led the development of thepractice standards; GH, SH and GS wrote the manuscript; all authors contrib-uted to the initial practice standards draft and read and approved the finalmanuscript.

FundingANZAED provided financial support for the meetings, public consultations,writing and publication costs associated with the development of thesepractice standards.

Availability of data and materialsNot applicable.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsNot applicable.

Author details1Executive Committee, Australia & New Zealand Academy for EatingDisorders, Sydney, Australia. 2School of Medicine, Western Sydney University,Campbelltown, Australia. 3Eating Disorder Service, Northern Sydney LocalHealth District, Sydney, Australia. 4Nutrition and Dietetics, St Vincent’sHospital, Darlinghurst, Australia. 5The Boden Collaboration of Obesity,Nutrition, Exercise and Eating Disorders, The University of Sydney, Sydney,Australia. 6School of Sport, Exercise and Nutrition, College of Health, MasseyUniversity, Auckland, New Zealand. 7The Swan Centre, Perth, Australia.8Centre for Psychotherapy, Hunter New England Local Health District,Newcastle, Australia. 9The Mindful Dietitian, Melbourne, Australia. 10River OakHealth, Brisbane, Australia. 11Royal Brisbane and Women’s Hospital, Brisbane,Australia. 12Victorian Centre of Excellence in Eating Disorders, Parkville,Australia. 13Eating Disorder Service, Robina Private Hospital, Robina, Australia.14Griffith University, Gold Coast, Australia.

Received: 5 August 2020 Accepted: 2 October 2020

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