eating disorder management in hospital patients: current practice among dietitians in australia

ORIGINAL RESEARCH

Eating disorder management in hospital patients:Current practice among dietitians in Australia

Susan HART,1,2 Suzanne ABRAHAM,1,2 Georgina LUSCOMBE1,2 and Janice RUSSELL2,3

1Department of Obstetrics and Gynaecology, Royal North Shore Hospital, 2The Northside Clinic, and 3Departmentof Psychological Medicine, University of Sydney, Sydney, New South Wales, Australia

AbstractAim: To examine dietetic practice during the management of eating disorders in inpatient and daypatient settings.Methods: A survey was sent to dietitians working in the clinical management of eating disorders within Australia.Thirty-six qualified dietitians including all dietitians working at the specialist units in Australia participated in thestudy.Results: Most dietitians aim to meet patients’ nutritional requirements by food alone without artificial feeding.High-energy supplements are the preferred method of increasing energy intake to eating disorder patients. Naso-gastric feeding was a standard feeding practice for anorexia nervosa reported by one-third of dietitians. Totalparenteral nutrition was not considered an option for nutritional rehabilitation. In the treatment of anorexia nervosa,variable energy intakes for individual patients were prescribed aiming for weight gain of up to 1.0 kg/week ininpatients and 0.5 kg/week in outpatients.Conclusion: In Australia, there is no standard nutritional management for anorexia and bulimia nervosa. Thissurvey establishes a baseline for nutritional management and practice of dietitians working with patients with eatingdisorders. Further research is needed regarding use of nasogastric feeding, and weight gain targets in anorexianervosa.

Key words: dietitian, eating disorders, nutrition, rehabilitation, survey

INTRODUCTION

An established goal is ‘nutritional rehabilitation’ and weightrestoration in anorexia nervosa and normalising of binge andpurge behaviours1–4 in bulimia nervosa. However, there islimited literature5–7 to guide us as to what is best practice inthe nutritional management of these patients. What exactlydoes a dietitian do who works with patients with eatingdisorders? What is an appropriate rate of weight gain? Whatis the level of compliance with prescribed meal plans? Notonly are answers to these questions unknown, they are dif-ficult to measure. Articles discussing nutrition, weight gainand feeding methods in eating disorders are often authoredby physicians and psychiatrists8–10 with some descriptions ofpractice by dietitians5–7,11. Advanced practice of dietitians as

nutrition counsellors or as nutrition therapists is an essentialbut neglected area of dietetics12 when working with eatingdisorders. The aim of this survey was to examine the practiceof dietetic experts who were currently treating patients witheating disorders (anorexia and bulimia nervosa) receivinginpatient or daypatient treatment and establish a baseline ofpractice in the treatment of eating disorders in Australia.

METHODS

The study was conducted by a written survey divided intofour sections to cover details of the individual practitionerand their service; the nutritional management of anorexiaand bulimia nervosa; meal structure and provision of foodby the service; and education sessions by the dietitian. Thesurvey asked 50 items, each item having between three to sixresponse options. Respondents were able to tick as manyoptions as applied to each item. At the end of each section,there was an open-ended item for ‘other comments’. Ethicsapproval was obtained from The University of Sydney EthicsCommittee.

A database of dietitians who were currently working ineating disorders was constructed by:1 The Dietitians’ Association of Australia email-based

network of dietitians interested in eating disorders;

S. Hart, MNutrDiet, APD, DietitianS. Abraham, PhD, Associate Professor, Co-Director Eating DisorderProgramG. Luscombe, PhD, Research AssistantJ. Russell, MD, FRACP, FRANZCP, ProfessorCorrespondence: S. Hart, Wallce Freeborn Block, RNSH, PacificHwy, St Leonards Sydney, NSW 2068, Australia. Email:[email protected]

Accepted April 2007

Nutrition & Dietetics 2008; 65: 16–22 DOI: 10.1111/j.1747-0080.2007.00174.x

© 2008 The AuthorsJournal compilation © 2008 Dietitians Association of Australia

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mailto:[email protected]

2 personal contact at Australian conferences and meetingswith dietitians who are recognised as specialists in themanagement of eating disorders;

3 direct mail out to specialist eating disorder units;4 Internet search of web-based Internet services, such as

Centre for Excellence in Eating Disorders and mail out tomental health hospitals (private or public), major paedi-atric hospitals, and women and children’s hospitals ineach capital city of Australia via the Nutrition andDietetics Department.A total of 335 surveys were distributed via email, personal

contact and by mail between February 2004 and September2005. Data were entered into SPSS Version 11.0 for analysis.

RESULTS

A total of 38 dietitians returned surveys, 36 were used foranalysis and two were discarded, as the respondents werenot currently treating eating disorder patients (Table 1).Thirty-one separate units were represented in the survey asthree units had multiple dietitians return surveys. Themajority of respondents worked in hospitals based in capitalcities: Sydney (11), Brisbane (8), Melbourne (6), Canberra(2), Hobart (2), Adelaide (2) and Perth (1). Three worked inservices in regional NSW and one in regional NorthernTerritory. Sixteen dietitians managed eating disorder patientsin a non-specialist eating disorder service while 20 dietitianswere working in specialist services (Table 2). Over half of thedietitians in the study (n = 19) had greater than four years’experience working with patients with eating disorders.Nine dietitians had seven to 10 years of experience and sixhad more than 10 years of experience with eating disorderpatients. The majority of dietitians (20) worked in unitswhere both adolescents and adults were treated. Nine dieti-tians worked in units where only adolescents 17 years andyounger were treated and seven dietitians where only adults18 years and older were managed.

Nutritional management ofanorexia nervosa

What feeding methods are used in anorexia nervosa?

The feeding methods for anorexia nervosa are shown inTable 3. Twelve dietitians reported using nasogastric (NG)

feeding as standard treatment and 15 dietitians reportedusing high-energy supplements as standard treatment.

How much weight gain is expectedin one week?

Assuming 100% compliance with prescribed meal plans,27 dietitians expect a weight gain of up to 1.0 kg per weekand seven dietitians expect greater than 1.0 kg per week.None of the 10 dietitians who expect a weight gainbetween 0 and 0.5 kg per week worked in specialist inpa-tient units.

How much energy is recommendedfor refeeding?

The most frequent response was ‘variable energy/kilojoulelevel’ with 21 dietitians recommending ‘variable energylevels depending on the patient’. Seven dietitians prescribedless than 10 460 kJ (2500 kcal), five of whom worked inspecialist units, while eight dietitians prescribed greater than10 460 kJ (2500 kcal).

What vitamins and mineral supplements areprescribed in anorexia nervosa?

Eighteen dietitians said they ‘always’ supplemented withvitamin and minerals as standard treatment in anorexianervosa; 16 said they would supplement if required forcorrection of deficiencies or electrolyte abnormalities; andtwo said they would not supplement (see Table 4 for adescription of vitamins and mineral supplements ‘often oralways’ used in management).

Compliance with meal plans inanorexia nervosa

Eighteen dietitians expect greater than 75% compliancewith prescribed meal plan with eight of the 18 dietitiansexpecting greater than 90% compliance. Of dietitians whoexpected high levels of compliance 14 worked in specialistunits. Seventeen dietitians believed that there is less than75% compliance with meal plans prescribed to patients ontheir unit (one dietitian did not respond).

Nutritional management ofbulimia nervosa

What feeding methods are used in bulimia nervosa?

There was no standard feeding method for bulimia nervosa(see Table 3). Twenty-nine dietitians aimed to meet nutri-tional requirements with food alone without any supplemen-tal feeding. Most (34 dietitians) would never use totalparenteral nutrition (TPN), fortifying powders (26 dietitians)or NG feeding (25 dietitians) to manage bulimia nervosa.

Table 1 Recruitment method and survey response

Method of recruitment Surveys sent Surveys used

1. DAA email network 263 102. Personal contact 11 113. Direct contact with

specialist units8 8

4. Mail out 53 7Total 335 36

DAA, Dietitians’ Association of Australia.

A survey of dietitians


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Nine dietitians would use high-energy supplements only inthe case of food being refused. None of the dietitianssurveyed said fortifying powders, NG feeding or TPN wasstandard treatment.

How much energy is recommended for management ofbulimia nervosa?

As for nutritional management of anorexia nervosa, the mostfrequent response by 18 dietitians was prescription of a

variable energy intake. Six dietitians said they would pre-scribe less than 8370 kJ (2000 kcal) and eight dietitianswould prescribe between 8370 and 10460 kJ (2001–2500 kcal) for patients.

Vitamin and mineral supplementation inbulimia nervosa

Six dietitians said they would ‘always’ prescribe vitamin ormineral supplements while 26 dietitians would prescribe

Table 2 Eating disorder treatment facility reported by dietitians

Hospital description n = 36

Specialist eating disorder service unit Adult specialist unit 12Child specialist unit 4Day specialist unit 4

Non-specialist eating disorder service unit Mental health facility 7General medical hospital 5General paediatric hospital 4

Table 3 Feeding methods in anorexia and bulimia nervosa

Anorexia nervosan = 36 (%)

Bulimia nervosan = 36 (%)

FoodAim to meet nutrient requirements by food alone 16 (44) 29 (81)Would not aim in meet requirements by food alone 11 (31) 3 (8)

High energy supplementsWould sometimes use high energy supplements 18 (50) 14 (39)Would use high energy supplements as standard treatment 15 (42) 1 (3)Would use high energy supplements only if food was refused (a) 9 (25)

Nasogastric feedingWould use NG feeding as standard treatment 12 (33) 0Would never use NG feeding 11 (31) 25 (69)Would sometimes use NG feeding 10 (28) 10 (28)Would use NG feeding if food was refused? (a) 0

Total parenteral nutritionNever use TPN 33 (92) 34 (94)Would use TPN as standard treatment 0 0

High energy powders/additivesNever use fortifying powders 23 (64) 26 (72)Would use high energy powders as standard treatment 2 (6) 0

(a) Not asked in anorexia nervosa.NG, nasogastric; TPN, total parenteral nutrition.

Table 4 Vitamin and mineral supplements used in management of anorexia and bulimia nervosa

Supplement ‘Often or always’ used in anorexia nervosa n = 36 (%) ‘Often or always’ used in bulimia nervosa n = 36 (%)

Multivitamin 20 (56) 12 (33)Phosphate 11 (31) 6 (17)Thiamine 10 (28) 2 (6)Calcium 9 (25) 6 (17)Potassium 5 (14) 7 (20)Magnesium 5 (14) 2 (6)Iron 2 (6) 2 (6)Zinc 2 (6) 0

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‘only when required’. The most popular supplement ‘oftenor always’ prescribed was a multivitamin by 12 dietitians; thesecond most common was potassium (Table 4).

Compliance of bulimia nervosa patients withmeal plans

Twenty dietitians expect 75% or greater compliance withmeal plans, similar to what was expected for anorexianervosa. Fourteen of the 20 dietitians reporting a high levelof compliance worked in specialist units. Ten dietitiansexpected between 51% and 75% compliance, two expectedless than 50% compliance, while one dietitian was unsure ofthe level of compliance in her unit.

What guidelines are in placeabout food?

It was common (n = 28) to give patients an option of exclud-ing foods that were disliked; however, there was a limit onthe number of foods that could be nominated. Unfortu-nately, most respondents did not mention the number offoods that could be nominated as a dislike. Of the 10 dieti-tians who did respond, seven allowed three dislikes andthree allowed two dislikes. It was common that patients werepermitted to choose vegetarian meals; however, veganism asa permitted option was less common. Typically, standardhospital food was supplied to eating disorder patients, withlow-fat food and modified diet products being less com-monly permitted (Table 5).

Frequency of weighing

The most common response for frequency of weighing wastwice weekly for both anorexia and bulimia nervosa (20dietitians), consistent with a previous study13. Eight dieti-tians weighed patients once weekly and five dietitiansweighed three times weekly.

How are food, meals and eating managed on eatingdisorder units?

The most frequent method of providing meals to eatingdisorder patients was in a group setting (see Table 6). Onedietitian reported that patients ate without supervision, asthere was ‘inadequate staff to supervise meals’. In the major-ity of units, two or more professionals shared the responsi-bility of meal supervision. The most frequent staff to patientratio (19 units) for meal supervision was one team memberfor four to six patients. Eleven units provided supervision ofone staff member to one to three patients, and three unitsprovided supervision of one staff member for seven patientsor greater.

How often do dietitians have contact with eatingdisorder patients?

Nineteen dietitians saw patients individually at a frequencyof twice weekly, 11 saw patients once a week, three said lessthan once weekly and one dietitian said only when con-sulted. Not all dietitians provided education in a groupsetting, 13 did not facilitate group education and five onlywhen consulted. Sixteen dietitians provided group educationonce weekly or more. The majority of these dietitians (12)were from specialist units.

Nutrition education

The topics in which dietitians provided education to eatingdisorder patients at the group or individual level are shownin Table 7. ‘Other’ topics for education included: normalis-ing eating behaviour; hunger and fullness regulation; guide-lines for appropriate eating/etiquette, that is, pace and timingof meals; body image; use of food as a coping strategy;

Table 5 Food guidelines in place on eating disorder units

Allow patients toYes

n = 36 (%)

Practise their religious exclusions 34 (94)Include soy milk as an alternative 31 (86)Allow patients to be vegetarian 29 (81)Patients have standard food provided

by hospital catering28 (78)

Exclude food that patients strongly dislike 28 (78)Milk-free diet (only if medically indicated) 18 (50)Allow special/favourite foods to be brought in

and eaten as alternative to hospital food16 (44)

Allow use of low-fat foods 13 (36)Allow patients to be vegan 9 (25)Use ‘diet’ foods 5 (14)Takeaway food as challenge once weekly 2 (6)

Table 6 Type of supervision of meals in eating disorderunits (multiple responses permitted)

Methods of meal supervisionof eating disorder patients

Number ofrespondents

Eat individuallyWith supervision 10Without supervision 5

Eat in a groupWith supervision (group of eating disorder

patients)25

Without supervision (group of generalmental health patients)

3

Type of supervisionNurses 29Dietitian 20Social worker/occupational therapist 12Psychologist 11Family members 7Programme assistants/support workers 5Doctor/psychiatrists 3



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challenging ‘unsafe’ foods; relaxation/distraction strategies toreduce anxiety over eating; exercise recommendations; ‘not’label reading; food faddism; vegetarian eating; and fluidintake.

DISCUSSION

There does not appear to be a standard practice in Australiafor nutritional management of eating disorder patients. Asurvey of dietetic practice in the United States in 199514

which focused on prevention, problems encountered duringtreatment, perceived needs for extra training, and knowledgeof psychological issues, also suggested that nutrition therapyof eating disorders varied among dietitians similar to theresults of this survey.

The role of the dietitian is infrequently documented in themanagement of eating disorders even though dietitians areoften referred to as part of multidisciplinary management.2

The current sample of dietitians is in a unique position toprovide expert advice on nutritional management as half ofthe sample had more than four years, 16 had more thanseven years of experience and all 20 dietitians working inspecialist units within Australia responded to the survey.

Weight gain

Recommended weight gain for inpatient treatment of anor-exia nervosa has been quoted as 0.9–1.4 kg per week.4 Therehas not been any large-scale study to determine rates ofweight gain in inpatient treatment of anorexia nervosa norhave there been studies comparing rates of weight gain andlong-term outcome with different feeding methods in terms ofretention of weight gained in hospital. There has been onestudy in 53 adolescent anorexia nervosa patients showing

average weekly weight gain to be 0.82 kg per week11. In oursurvey of 36 dietitians, 27 dietitians expected a weight gain of0–1.0 kg per week consistent with the National Institute forClinical Excellence (NICE) guidelines.3 It is likely that inoutpatient or daypatient treatment, 0.5 kg per week is areasonable target, as there is a percentage of time wherepatients are not having supervised, controlled eating. Half akilogram per week weight gain is consistent with outpatientrecommendations.3 These results highlight that standardtargets of greater than 1.0 kg per week are unrealistic as mostexperienced dietitians in Australia would not expect thatmuch weight gain even in inpatients settings where treatmentis controlled and supervised by experienced staff.

Feeding method

There are case reports and individuals who advocate certainfeeding methods9,10,15,16, but with no comparative groups andsmall numbers, it is hard to conclude efficacy from suchreports. This survey found most dietitians did not have astandard energy prescription or feeding method for achiev-ing weight gain in anorexia nervosa. The consensus was thatmost dietitians aimed to meet nutritional requirements withfood alone rather than using supplemental or enteralfeeding.

The use of NG feeding was divided into thirds betweendietitians who used NG feeding as ‘standard treatment’,those who would ‘never’ use it and those who would use itsometimes if adequate food was refused. While there arereports of using TPN in anorexia nervosa,15 in this sample itwas the least popular feeding method with 34 dietitianspreferring ‘never’ to use it as an option in management.Using high-energy supplements8 in addition to food to meethigher energy requirements was a more frequent choice.

High-energy supplements provide greater energy densitythan food but without the invasiveness that is fundamentalto NG feeding and TPN; and also provide a solution to theproblem of tolerating the large volumes of food often neces-sary for weight gain. The use of fortifying powders to achieveweight gain was not considered a suitable option for nutri-tional rehabilitation of anorexia nervosa. More researchneeds to be performed with varied feeding methods, as thereis no study, which demonstrates the superiority of onefeeding method over another. There are many questionsraised about best practice in the nutritional management ofeating disorders. Best practice should address not only short-term outcomes such as weight gain but also longer-termoutcomes such as retention of weight gained in treatmentand normalisation of eating behaviours. Artificial feeding(NG or TPN) appears to be more medically than dieteticallydriven.9,10,15 There is evidence that artificial feeding mayresult in quicker weight gain in the short term,9 but does itlead to better outcome after 12 months? Does this teachpatients the true nature of food and its effects on the body ordoes it heighten patient’s fear of food? Does it prevent peoplelearning ‘normal eating’? Future research needs to examinethese issues as well as the benefits and/or harm of NGfeeding in treatment of anorexia nervosa.

Table 7 Topics about which dietitians educate eatingdisorder clients

Education topic n = 36 (%)

General nutrition and core food groups 34 (97)Menu planning 34 (97)Gut function 33 (92)Consequences of restriction and dieting 33 (92)Dietary iron requirements 33 (92)Calcium requirements & osteoporosis 33 (92)Metabolism and energy requirements 32 (89)Consequences of binge eating and vomiting 30 (83)Food outings and social eating, i.e. eating in

a cafe28 (78)

The binge eating cycle 27 (75)Shopping skills 24 (67)Cooking skills 22 (61)Family meal plans 21 (58)Strategies for preventing relapse 19 (53)Dental health 17 (47)Set point theory 17 (47)Other 12 (33)

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Supplementing food intake with vitamins and mineralsalso requires more research. Thiamine and phosphate isrecommended for the prevention and management ofrefeeding complications2 and supplementation of calcium,17

iron18 and zinc2 is also reported. In line with the literature,in the treatment of anorexia nervosa, multivitamins,calcium, phosphate and thiamine were the most popularvitamins and minerals ‘often or always’ prescribed by dieti-tians surveyed. Twenty dietitians routinely prescribed amultivitamin in anorexia nervosa and 12 in bulimianervosa consistent with NICE guidelines.3 Potassiumsupplementation was the second most frequent response inmanagement of bulimia nervosa, in line with the knownside effects of weight control behaviours that may result inpotassium depletion2. However, the number of dietitiansin this survey who routinely supplement with vitaminand mineral supplementation was not great. A survey ofoutpatient dietitians may yield different results where thereis less control and supervision of food by the treatmentteam.

Mealtime food and nutrition policy

It is difficult to assess and measure what is an appropriatelevel of compliance with treatment recommendations foreating disorder patients. The best measure of compliance israte of weight gain, because if there is no weight gain, thereis a relative lack of energy because of inadequate food intakeor purging of food by vomiting or exercise. It is more diffi-cult to restrict food intake on an eating disorder unit than athome, but patients often report how they were able to avoidfood on their meal plan via ‘scamming’ which describesbehaviours that aim to minimise the amount of foodingested. Methods of scamming include hiding food inpockets, emptying milky drinks into plant pots or wipingspreads off toast onto clothing.

Managing a food and mealtime policy on the eating dis-order unit is an important role for the dietitian who needs toliaise with patients, the medical team and nurses to ensure allrecommendations are implemented at the catering level. It isnecessary to have guidelines to make it clear to staff, patientsand family what is expected of patients and to ensure aconsistent approach from all team members (Table 5).

Education

Dietitians commonly educate eating disorder patients ontraditional nutrition education such as core food groups,psycho-educational topics and practical aspects of nutri-tional rehabilitation, such as food outings/social eating,shopping and cooking skills, and eating with the family.Eating disorder patients find the practical aspects of eatingdifficult once they are refed and are at an appropriate weight,or ceased their bingeing and vomiting5. Assisting patientswith the skills of normal eating once discharged from arefeeding programme may be a simple and effective way toimprove weight retention.

CONCLUSION

No articles on dietetic practice in eating disorders in Austra-lia were found via Medline and Cinahl, and only two articleswere found internationally. Therefore, this survey aimed todescribe basic dietetic practice of dietitians who treat eatingdisorders patients who are hospitalised. It did not aim toprovide conclusive recommendations in management, butrather to establish a baseline from where further research canbe extended. This survey highlights that the specialty ofeating disorders is a small area of dietetic practice anddescriptions of practice are limited. Further research isneeded to describe and establish best practice for dieteticmanagement of eating disorders.

Limitations of the survey

As there are limited descriptions of dietetic practice in eatingdisorders, there was little to guide the authors in surveydesign. As the authors are experienced clinicians in eatingdisorder management, it is possible that the survey is biasedtowards describing the authors current practice rather than abroad description of dietetic practice in eating disorders.

The numbers in the study were relatively small comparedwith the number of dietitians practicing in Australia, and thesurvey targeted a very specialised area of dietetic practice,those patients who are receiving inpatient or daypatienttreatment. The majority of patients with eating disorders arelikely to be managed as outpatients rather than a day orinpatient setting,2,3 so it would be worthwhile to repeat thesurvey in a larger number of dietitians and extend it to anoutpatient setting. More variations in practice may be found.

This survey also did not address use of advanced practicetechniques of nutrition counselling (such as rapport buildingstrategies, content-focused behavioural change strategies andprocess-focused behaviour change strategies12), which are asignificant aspect of working with eating disorder patients.

REFERENCES

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2 Beumont P, Hay P, Beumont D et al. Australian and NewZealand clinical practice guidelines for the treatment of anorexianervosa. Aust N Z J Psychiatry 2004; 38: 659–70.

3 Wilson GT, Shafran R. Eating disorders guidelines from NICE.Lancet 2005; 365: 79–81.

4 American Psychiatric Association Work Group on Eating Disor-ders. Practice guideline for the treatment of patients with eatingdisorders (revision). Am J Psychiatry 2000; 157 (1 Suppl.):1–39.

5 Herrin M. Balancing the scales. Nutritional counseling forwomen with eating disorders. AWHONN Lifelines 1999; 3 (4):26–34.

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8 Imbierowicz K, Braks K, Jacoby GE et al. High-caloric supple-ments in anorexia treatment. Int J Eat Disord 2002; 32 (2):135–45.

9 Robb AS, Silber TJ, Orrell-Valente JK et al. Supplemental noc-turnal nasogastric refeeding for better short-term outcome inhospitalized adolescent girls with anorexia nervosa. Am J Psy-chiatry 2002; 159: 1347–53.

10 Neiderman M, Zarody M, Tattersall M, Lask B. Enteric feedingin severe adolescent anorexia nervosa: a report of four cases. IntJ Eat Disord 2000; 28: 470–75.

11 Davies S, Jaffa T. Patterns of weekly weight gain during inpa-tient treatment for adolescents with anorexia nervosa. Eur EatDisorders Rev 2005; 13: 273–7.

12 Cairns J, Milne RL. Eating disorder nutrition counseling: strat-egies and education needs of English-speaking dietitians inCanada. J Am Diet Assoc 2006; 106: 1087–94.

13 Touyz SW, Lennerts W, Freeman RJ, Beumont PJ. To weigh ornot to weigh? Frequency of weighing and rate of weight gain in

patients with anorexia nervosa. Br J Psychiatry 1990; 157:752–4.

14 Whisenant SL, Smith BA. Eating disorders: current nutritiontherapy and perceived needs in dietetics education andresearch. J Am Diet Assoc 1995; 95: 1109–12.

15 Mehler PS, Weiner KL. Anorexia nervosa and total parenteralnutrition. Int J Eat Disord 1993; 14: 297–304.

16 Tonoike T, Takahashi T, Watanabe H et al. Treatment with intra-venous hyperalimentation for severely anorectic patients and itsoutcome. Psychiatry Clin Neurosci 2004; 58: 229–35.

17 Mehler PS. Osteoporosis in anorexia nervosa: prevention andtreatment. Int J Eat Disord 2003; 33: 113–26.

18 Kennedy A, Kohn M, Lammi A, Clarke S. Iron status andhaematological changes in adolescent female inpatients withanorexia nervosa. J Paediatr Child Health 2004; 40: 430–32.

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eating disorder management in hospital patients: current practice among dietitians in australia

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