Best Nutrition Counseling Practices for the Treatment of Anorexia Nervosa

Published: 24 July, 2014

Anne Mittnacht, a former member of the Bulik lab and recent graduate of the MPH/RD program in the Gillings School of Global Public Health at UNC-Chapel Hill, conducted a Delphi Study as part of her Master’s work to evaluate consensus on nutrition counseling practices among registered dietitians (RDs) treating patients with eating disorders. Limited research and lack of evidence-based information on nutrition intervention for treating anorexia nervosa (AN) has often resulted in RDs basing treatment plans on personal experience. Delphi methodology, which uses iterative questionnaires to evaluate consensus among a panel of experts on topics in their field, provided a way to determine points of agreement and discord in the current practices of RDs treating individuals with AN.

Email invitations to participate in the study were sent to RDs identified as having expertise in treating eating disorders based on their participation in eating disorders conferences and authorship of seminal books, book chapters, and articles on nutrition counseling practices for treating eating disorders. Of the 45 RDs invited, 21 ultimately comprised the Delphi panel. Panelists were almost exclusively (95.2%) female, had been working as RDs for an average of 21 years (SD 10, range 5-35 years), had specialized in treating eating disorders for an average of 14 years (SD 8, range 5-30 years), and had worked in a variety of treatment settings (including inpatient, residential, outpatient, and private practice).

The panel completed three rounds of online questionnaires over a 10-week period in Fall 2013. The first questionnaire included 12 open-ended questions, and a content analysis of panelist responses generated 15 categories and 133 corresponding summary statements that were ranked and re-ranked in rounds two and three using a five-point, Likert scale (with responses ranging from “strongly disagree” to “strongly agree”). Panelists ultimately achieved consensus (≥85% chose “strongly agree” or “agree” for agreement or ≥85% chose “strongly disagree” or “disagree” for disagreement) on 47 (35.3%) of the 133 items, including the following thematic areas:

  • Patient goal setting (e.g., a good strategy is to begin with modest, achievable goals that will enable the patient to develop a sense of capacity and success)
  • Goal weights for children and adolescents (e.g., should be based on growth trends or growth charts)
  • Addressing weight goals/weight changes with patients (e.g., eating disorder dietitians should encourage patients to think about achieving a healthy state rather than a healthy weight)
  • Eating plans for patients with AN (e.g., eating disorder dietitians should take what patients are already consuming and modify it for improvement)
  • Addressing body image and other psychological issues (e.g., an eating disorder dietitian’s role is to help patients work through misbeliefs and distortions regarding food, health, metabolism, and weight)
  • Applying psychological therapy techniques during nutrition counseling sessions (e.g., eating disorder dietitians should use motivational interviewing techniques)

In general, the consensus items described treatment approaches that will work with any patient and leave room for clinical judgment. Consensus was not achieved regarding using any specific food plan with AN patients, or on items discussing goal weights for adult patients, and the modest consensus rate reflects panelists’ views on the importance of individualizing treatment approaches based on the patient’s age, sex, stage of illness, eating disorder history, etc. This lack of consensus underscores the need for more studies of nutrition intervention in AN, as a stronger evidence base would allow RDs to provide more consistent care to eating disorders patients and improve the quality of available resources.


Mittnacht AM, Bulik CM. Best nutrition counseling practices for the treatment of anorexia nervosa: A Delphi study. Int J Eat Disord. 2014 Jun 27. doi: 10.1002/eat.22319. PMID: 24976176.

photo credit: hamadryades via Creative Commons