Anorexia nervosa (AN) is a severe eating disorder (ED) marked by an intense fear of weight gain and a distorted body image, with extreme food restrictions and dangerously low body weight. AN affects approximately 4% of females and 0.3% of males over the course of a lifetime, bringing numerous physical complications and a concerning 39.4% readmission rate for previously hospitalised patients (Marzola et al., 2021; Mehler et al., 2015; van Eeden et al., 2021). Guidelines from the National Institute for Health and Care Excellence (NICE) and the American Psychiatric Association (APA) emphasise weight restoration as a treatment goal, yet patients’ anxiety around calorie intake often impedes this process.
Mealtimes are often anxiety-provoking for AN patients, making psychological support during mealtime intervention crucial for weight restoration and reducing ED behaviours (Long et al., 2012). This blog describes a systematic review conducted by Komarova et al. (2024) that explores both patient and clinician perspectives on supported mealtimes, which are defined as the oral consumption of food with clinician support under clear guidelines (e.g., set meal duration). By synthesising these qualitative insights, the review aims to bring attention to the challenges of current practices and guide the development of more empathetic and effective treatment.
Anorexia nervosa has a high relapse risk, posing a risk to both psychological and physical health. Further research is needed to develop sustainable treatment and maintain healthy eating habits among patients with anorexia nervosa.
Methods
The authors conducted a comprehensive search for peer-reviewed qualitative or mixed-method studies on three databases up to November 20th 2023. The search used combinations of “anorexia nervosa”, “treatment”, and “experience/perspective/view”, with family meals and nasogastric feeding studies excluded. To enhance reliability, 10% of the studies were double-screened by two researchers, with discrepancies resolved through discussion. Data extraction was also conducted by two researchers. This process led to the inclusion of 26 relevant studies on supported mealtimes, with most studies demonstrating good quality as evaluated by the CASP checklist.
The studies were analysed using the thematic synthesis approach outlined by Thomas and Harden (2008), with coding following deductive thematic analysis (Braun & Clarke, 2006). This involves systematically coding the text and developing both descriptive and analytical themes, providing a comprehensive understanding of the perspectives of both patients and clinicians.
Results
Twenty-six papers met the criteria for this review, with data primarily collected from inpatient clinical settings (n = 22). A total of 542 patients and 115 clinicians were included in these studies, with over 95% of the patients being female, ranging in age from 11 to 72 years. Most studies took place in Europe (n =17, including 10 from the UK), with a further seven from Australia, one from New Zealand, and one from Taiwan.
Clinicians’ experiences (from 10 papers)
1. Implementation of mealtime support
Clinicians with varied clinical training may provide mealtime support differently, which affects overall consistency in care provision and leads to frustration. While clinicians underscored the importance of establishing rules and restrictions, they also acknowledged flexibility for addressing patients’ needs; but the ability to be flexible was challenging and often relied on the clinician’s experience and judgment. Organisational aspects such as adequate staffing, effective teamwork, and standardised setup were deemed essential. Family support and involvement were highlighted as particularly beneficial for adolescent patients.
2. Power and authority
Power dynamics were perceived negatively, with clinicians feeling that some rules created a battle-like atmosphere, where they observed that patients felt punished and described mealtimes as a metaphorical prison. However, Bakker et al. (2011) noted that transferring control from patients to clinicians might help in the initial stages of treatment. This requires clinicians to take charge of decisions around food, aiming to gradually grant patients more independence while initially challenging the distorted eating behaviours.
3. Emotional experiences
Clinicians often experienced discomfort, anxiety, self-doubt, and frustration, especially those new to providing mealtime support, which was often compounded by a limited understanding of psychological factors driving patients’ behaviours. Many clinicians struggled with a lack of confidence, particularly when they encountered resistance from patients.
Patients’ experiences (from 18 papers)
1. Practical aspects of supported mealtimes
Patients emphasised that addressing psychological factors was equally crucial as mealtime support, and an excessive focus on food intake alone was not beneficial in the long term. A dining environment that included distractions was perceived as more conducive to a positive mealtime experience, and patients expressed their need for a wider variety of food options. They also appreciated having their food preferences respected, rather than being automatically attributed to ED cognitions. A sense of normality was highly valued by patients, which was achieved through casual conversations with clinicians or peers; however, discussions about “food, calories and comparison of portion sizes” were seen as unhelpful during mealtime.
Patients agreed with clinicians about the need for a balance between clear rules and punishments and flexibility to minimise anxiety. Further, allowing clinicians to take control could help reduce patients’ guilt about eating. In general, clinician conduct was important in alleviating mealtime anxiety. Patients also viewed eating as a skill to be relearned with clinicians’ support, and post-meal debriefing and support from both clinicians and peers were beneficial.
2. Personal experiences of supported meals
Patients frequently mentioned their emotional experiences during mealtimes, including “anxiety, embarrassment, anger, and sadness”, with guilt being the most common. They also reported negative physical sensations that were often met with a lack of empathy from clinicians.
3. Interpersonal experiences of supported mealtimes
Eating with peers brought mixed outcomes for patients. While competition and comparison could exacerbate ED behaviours and even lead to the adoption of others’ symptoms, peer support was often perceived as more genuine and motivating than support from clinicians.
Both patients and clinicians highlighted the emotional complexities of mealtime support, emphasising the need to balance structured support with flexibility to meet individual needs.
Conclusions
- Mealtimes can provoke challenging emotions for anorexia patients and clinicians.
- Whilst both groups recognised that consistent and structured care during mealtime support could help alleviate patient anxiety, incorporating flexibility also seemed beneficial.
- Patients generally viewed the support from clinicians and peers during and after meals positively, and preferred a mealtime setting that mirrored real-life scenarios.
- Clinicians were more concerned about power dynamics and that it might appear as if they were “policing” the patients (Ryu et al., 2021).
- Despite feeling uneasy about these dynamics, patients highlighted that their discomfort stemmed mostly from perceiving a lack of understanding from the clinicians.
Patients value the care from clinicians during and after mealtime, finding emotional support and consistent care essential for managing anxiety and relearning healthy eating behaviors.
Strengths and limitations
Strengths
This review was preregistered on PROSPERO and followed PRISMA guidelines, which demonstrated rigour and established transparency. By searching the reference lists of relevant papers, the chance of missing pertinent literature was minimised. The studies discussed in this paper underwent a rigorous screening process using the CASP checklist, enhancing the reliability of the review by ensuring the included study asked clear questions and used sound methodology.
By incorporating the perspectives of both patients and clinicians, this review fosters mutual understanding of different stakeholder needs and emotional experiences, particularly in recognising the frustrations they may feel during mealtime. The qualitative nature of the data allows for a nuanced exploration of the emotional aspect, as participants could articulate their most salient experiences in their own words, capturing details that might be overlooked in quantitative studies.
Limitations
Analysis was primarily carried out by a single researcher, introducing a level of subjectivity and potentially bias. Although some double-screening (10%) and extraction were conducted with an additional researcher, they were limited in scope, and no kappa values were reported for inter-rater reliability. While the paper acknowledges this as a limitation, it could impair overall reliability of the study.
Moreover, most of the studies included in this review were conducted with predominantly White female populations from Europe or Australia. This lack of diversity raises concerns about the generalisability of the findings to other demographic groups, particularly those from different cultural backgrounds, where expectations and experiences of treatment may vary significantly (read Andie’s Mental Elf blog to learn more about eating disorder prevalence among multiracial individuals).
Another limitation is excluding the perspectives of caregivers, who play an indispensable role in the treatment journey (Anastasiadou et al., 2014; Rodgers et al., 2024). Including their viewpoints could have provided insights into the sustainability of mealtime support outside of the treatment setting.
In addition, the variation in background and training levels of those providing mealtime support across different studies is not adequately addressed in this paper, and a discussion of how clinicians’ training background could potentially shape viewpoints would bring additional insights to data analysis. Since the effectiveness of the intervention could be influenced by their background, it may impact patient outcomes such as eating behaviours and anxiety levels (Monteleone et al., 2024). Future studies should consider these factors to determine how they contribute to the success of mealtime interventions.
The screening and selection of papers was mostly conducted by one researcher, which could indicate potential bias and a lack of reliability in the studies included.
Implications for practice
This systematic review stresses the need for standardised and clear guidelines for mealtime support in the treatment of anorexia nervosa (AN). Protocols should ideally be informed by qualitative studies such as the ones included in this review, alongside quantitative studies that investigate mealtime intervention models to identify effective ways to mitigate patient anxiety and improve meal intake. A structured protocol would help provide consistency across various treatment settings, which could reduce patients’ confusion and anxiety if undergoing multiple treatment programs. However, these protocols must also leave some space for flexibility to accommodate individual needs, considering factors such as treatment trajectory, medical complexities, and personal food preferences.
The development of a structured protocol could also help streamline training for clinicians. Insights from qualitative studies can provide guidance on specific aspects of training that should be included (e.g., balancing structure with flexibility, deepening understandings of AN cognitions and eating disorder (ED) behaviours). Training also needs to address the inherent power dynamics, equipping clinicians with skills to navigate these dynamics without creating an environment where patients feel judged or coerced. Consolidating training in such a way can encourage more empathetic and supportive interactions between clinicians and patients, ultimately improving the therapeutic relationship and outcomes.
Furthermore, quantitative research is needed to evaluate and improve mealtime interventions. Future studies should examine how varying levels of structure affects outcomes such as weight gain, emotional well-being, and long-term recovery, while considering factors such as ED severity, therapeutic approaches, and patient characteristics (e.g., age, comorbidities). Treatment follow-up is also essential to assess the long-term impact of mealtime interventions, and identify relapse predictors, helping to develop targeted strategies for sustained recovery.
Standardising mealtime protocols and enhancing clinician training could foster understanding in anorexia nervosa treatment, leading to improved therapeutic relationships and (hopefully) better outcomes.
Statement of interests
The authors have no relevant interests to disclose.
Links
Primary paper
Komarova, D., Chambers, K., Foye, U., & Jewell, T. (2024). Patient and clinician perspectives on supported mealtimes as part of anorexia nervosa treatment: A systematic review and qualitative synthesis. European Eating Disorders Review, 32(4), 731–747.
Other references
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Ashdown, A. (2022). Unique multiracial identities may serve as protective or risk factor for eating disorders. The Mental Elf.
Bakker, R., van Meijel, B., Beukers, L., van Ommen, J., Meerwijk, E., & van Elburg, A. (2011). Recovery of normal body weight in adolescents with anorexia nervosa: The nurses’ perspective on effective interventions. Journal of Child and Adolescent Psychiatric Nursing, 24(1), 16–22.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
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van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 34(6), 515–524.
