A Narrative Literature Review to Investigate the Effectiveness

Introduction

Eating disorders are a form of mental disorder that is characterized by abnormal eating habits that lead to serious mental and physical health issues (Murphy, Straebler, Cooper, & Fairburn, 2010). According to Lock (2010), some of the most common eating disorders include anorexia nervosa that is manifested in the habit of eating tool little in fear of gaining body weight, binge eating which is characterized in eating large amount of food for a short period of time, bulimia nervosa, which is characterized by eating a lot then attempt to get rid of the food, pica whereby an individual eats non-food items and rumination syndrome where people regurgitate food (Lock, 2010).

While the exact cause of eating disorders is not clearly known, scientists speculate that both environmental and biological factors may come into play (Walsh, 2011). Furthermore, Walsh, (2011) observes that some people may develop a cultural idealization of thinness thereby developing eating disorder habits. In another study by Grange, Lock, Loeb, Loeb, & Nicholls (2009), eating disorders were attributed to sexual abuse, while other eating disorders such as rumination disorder and pica are attributed to mental disabilities (Grange, Lock, Loeb, Loeb, & Nicholls, 2009). Interestingly though, only one eating disorder can be diagnosed at a time.

In earlier years of its discovery, it was believed that eating disorders were more prevalent in Caucasian women of higher socio-economic status but currently there is a consensus that this is not true (Lock, 2010). Today, eating disorders are prevalent in many countries across the world and can be diagnosed among both genders and various age groups. In the UK, it is estimated that at least 1.25 million people have eating disorders and while this data has been validated with well-designed research, it is not a conclusive evidence over the exact number of people with eating disorders in the UK.

Despite the inconclusive prevalence estimates of eating disorders in the UK, existing literature has documented eating disorders as a form of mental illnesses with serious care and cost burdens that need effective healthcare attention like other forms of mental illnesses such as bipolar disorder, depression or obsessive, and compulsive disorder among others (Walsh, 2011). Particularly, literature by Klump et al (2009) state that nervosa is considered one of the most dangerous forms of eating disorder that countries like the USA have registered 12 times more premature fatality rates among females of age 15-24 compared to other causes of deaths. However, according to Garg, Hackam, & Tonelli (2008), most people with eating disorders do not receive any medical interventions in the UK. Moreover, despite the proven dangers of eating disorders, they are still not considered a serious mental illness and most of the people who have it do not receive treatment; or have serious financial problems that prevent them from seeking medical assistance (Grange, Lock, Loeb, Loeb, & Nicholls, 2009). Surprisingly, even though eating disorders have a higher prevalence globally compared to diseases such as Alzheimer’s disease (Grange, Lock, Loeb, Loeb, & Nicholls, 2009), there is still a general lack of funding and insurance cover for its interventions (Sun & Liu, 2013).

Etiology of Eating Disorders

Mazzeo & Bulik (2009) observes that whereas eating disorders begin with the victim’s preoccupations with weight and food, the causes of eating disorders are often complex, unique and predominantly within the individual. In fact, medical practitioners that work with eating disorder patients have noted a similarity between the disorder and addiction, both of which are characterized by loss of control over one’s behavior, repetitive dysfunctional behaviors and compulsion that they maintain for longer periods despite their dangerous consequences (Costa, 2009). Besides, eating disorders develop from emotional, biological, interpersonal, social and behavioral factors – just like other addictive disorders. In most cases, individuals with eating disorders view eating as a way of coping with certain emotional difficulties or as a means of demonstrating power over something in their lives.

Earlier research by National Eating Disorder Association (2004) revealed that individuals with eating disorders display several psychological issues such as depression, loneliness, anger, low self-esteem or anxiety. Interpersonal factors such as relationship break ups, history of sexual abuse, difficulty in expressing emotions and feelings, as well as history of ridiculed weight gain may also contribute to eating disorders (Wilson & Shafran, 2005). In another study by Klump et al (2009), the researchers hinted an association between eating disorders and social issues such as high regards to physical appearance, cultural pressures, and ‘thinness’ as a measure of beauty. Nonetheless, scientists have also attributed eating disorders to biological/genetic factors. However, regardless of the speculations on what could cause eating disorders, there is a consensus across most studies that it has serious negative impacts on individual’s health and well-being (Mazzeo & Bulik, 2009). The range of negative effects highlight the importance of further research on the various treatment options for eating disorders that can improve the general well-being of the patients.

Statement of the Problem

Occupational therapy has largely been used in enhancing and improving the performance and function in individuals with various health conditions. However, although its use has largely been popular among physically challenged populations, the use of occupational therapy in populations with behavioral and cognitive conditions that result into impaired function is less popular (Casiero & Frishman, 2006). Consequently, workforce occupational therapy has seen a decreased use within mental healthcare settings including eating disorders.

The practice of occupational therapy in the UK is largely regulated by the Royal College of Occupational Therapists (RCOT) who rely on several other legislations such as the Care Act 2014 to develop guidelines of practice. Thus, professional occupational therapists must comply with the various principles of the Care Act 2014 handling their patients. For instance, the Care Act stipulates that every occupational therapist is obligated promote the general the well-being of their clients. Therefore, it would be interesting to evaluate evidence on the effectiveness of occupational therapy as an intervention for eating disorders and how it can be practiced with respect to RCOT and Care Act’s guidelines.

Some scholars speculate that the generally low use of occupational therapy for eating disorders is attributable to a paucity of incidence-based research (Smink, Hoeken, & Hoek, 2012). However, a thorough review of literature reveals that among the available studies on occupational therapy as an intervention for eating disorders, only a few are systematic or narrative reviews on how occupational therapy treats eating disorders while other articles discuss the types of occupational therapies used with the population. For example, Gardiner & Brown discussed the MOHO’s model of practice as a guideline for assessing and treating people with eating disorders. To fill this research gap, the proposed study aims to conduct a narrative literature review on the effectiveness of occupational therapy as an intervention for eating disorders.

Research objectives

To identify existing evidence on the effectiveness of occupational therapy as a treatment for eating disorders

To identify the different approaches of occupational therapy used in treating different types of eating disorders

To identify solutions for the challenges faced by occupational therapists to treat eating disorders.

Research Questions

What are the evidences on the effectiveness of occupational therapy as a treatment for eating disorders?

What are the different approaches of occupational therapy used in treating different types of eating disorders?

What are the solutions for the challenges faced by occupational therapists to treat eating disorders?

Literature review

The modern society is familiar with cases of eating disorders as a highly prevalent health disorder among individuals of all ages. Children, middle-aged individuals and those in the older age categories of the population are said to have eating disorders when they are having irrational body perceptions towards food or with severe eating disturbances (Goebel-Fabbri, 2008). Often, they develop poor long-term prognosis, leading to serious psychological and physical complications (Goebel-Fabbri, 2008). People with eating disorders have abnormal eating behaviors that develop from controlled dieting. Upon developing controlled eating habits, they create meaning, purpose and fulfilment out of the habit so much so that it influences their social functioning, well-being and quality of life (Touchette, et al., 2011). Consequently, they develop certain social and psychological skills that exacerbate certain maladaptive coping skills (Touchette, et al., 2011). Nonetheless, while Literature by Klump et al (2009) and Lock & Pepin (2010) suggest that individuals with eating disorders have impaired occupational participation especially with regards to productivity, leisure and self-care; there is a paucity of literature on the effectiveness of occupational therapy as an intervention for eating disorders (Lock& Pepin 2010, Kloczko & Ikiungu 2006).

According to an earlier study by Steinglass et al (2012), people with an eating disorder had a relapse rate of 30-50% leading to rehospitalization within one year of discharge. However, decades of scientific research have led to the development of various treatment interventions creating more need for further research on better and long-term interventions (Nishizono-Maher 2011). In this regard, studies by Hay et al (2013), and Lock et al (2012) found that some of the causes of relapse include the inability to maintain the normal eating pattern, impaired psychosocial functioning, and fear of weight gain. Furthermore, Lock & Pepin (2010) speculated that the problem of eating disorders is often compounded by emotional difficulties and self-rejection associated with the demands of adult relationships. These pieces of literature, therefore, suggest that people develop eating disorders when they develop distorted cognition that contributes to the maladaptive lifestyle and eating habits.

There is evidence of occupational-based approaches as useful interventions that help victims of eating disorders to apply their functional skills within various experiential environments (Lock & Pepin 2010). Studies by Lock et al (2010) revealed how skill-building and practical exposures can assist individuals to develop their eating behaviors. Upon a one-year follow-up, the authors found that individuals with eating disorders were more able and motivated to engage in meal competency tasks if they engage in din meal preparation. This study provided evidence of occupational therapy as a possible intervention for eating disorders, although the researchers suggested further research in this area.

Theoretical Framework

Various theoretical models have been proposed to understand the eating disorder and how occupational therapy might help address it. For instance, the Model of Human Occupation (MoHO) (Kielhofner, 2008) emerges as a significant theoretical model that researchers have used in the context of eating disorders. Believers in this model use it to explain how occupations are selected, motivated and applied in an individual’s case.

The Model of Human Occupation suggests that motivation towards participation has the greatest impact on individuals with eating disorders and that for such individuals to function effectively, the need performance, habitual and motivational skills (Lock, 2000). Furthermore, literature by Lock & Pepin (2010) reveals that people with eating disorders have dysfunctional eating behaviors and maladaptive coping mechanisms that can develop into a habit over time. Thus, one of the most important approaches to recovery is changing their motivation and attitude towards eating.

Believers in the Model of Human Occupation also incorporates a client-centered approaches to eating disorders and argues that human desires also play an essential role in developing effective therapy. Because individuals with eating disorders often lack motivation particularly in social places, an occupational therapist’s focus should be on addressing the client’s lack of motivation and help them learn the required behaviors for proper participation (Lock, 2000).

Chisuwa & O'Dea (2010) observes that individuals with eating disorders have difficulty in self-care activities such as meal preparation because of resistance to change, poor self-competence and fear of weight gain. Furthermore, Klump et al (2009) note that such individuals may fail to participate due to lack of social leisure experience or a feeling of self-inefficiency. Similar remarks have been made by Walsh (2011) who asserts that poor performance among individuals with eating disorders can be caused by poor social skills, limited psychosocial functioning and lack of support.

Against this backdrop, Keilhofner (2008) notes that the Model of Human Occupation theory takes an open system approach that considers individuals and their contexts to explain how social insensitivity associated with mental illness and negative stigma influences further habituation, volition and performance capabilities. Moreover, because such individuals view themselves as inferior, worthless and incapable of participating in any occupation, a negative cycle that worsens the individual’s eating disorders may form (Fairburn et al 2003).

A significant role of occupational therapy as an intervention for eating disorders is to help individuals with real-world application of functional skills. According to Lock et al (2012), this correlates with the Model of Human Occupation by acknowledging that the outcomes of occupational therapies are largely influenced by how the individual interacts with their environment. An individual’s physical, social, political and economic environment can affect their performance, organization and motivation towards their occupational life (Helder & Collier, 2010). Thus, According to Lock et al (2012), the Model of Human Occupation provides a framework through which occupational therapists can encourage individuals with eating disorders to participate in important activities through reality-oriented, educational and experiential activities within a supportive environment. Occupational therapists believe that, by engaging individuals with eating disorders in various activities such as meal preparation, can help the clients develop the require internal motivation to adopt self-controlled eating behaviors, overcome anxieties and develop the necessary coping strategies (Chisuwa & O'Dea, 2010).

Research Method

The proposed study aims to explore the available evidence confirming the effectiveness of occupational therapy as an intervention for eating disorders. Eating disorders have remained an interesting topic within the healthcare academia with most researchers not only focusing on the causes of eating disorders but also the possible interventions to it. Therefore, it is important to explore the existing evidence-base on eating disorders and whether occupational therapy can be an effective intervention. This calls for a rigorous search of existing literature material and research papers that have investigated this issue.

The proposed study seeks to use a ‘narrative literature review research method’ to achieve its objectives. This entails critically evaluating the available research evidence on the effectiveness of occupational therapy as an intervention for eating disorders. Like other types of literature reviews such as systematic literature review, narrative literature reviews are a form of desktop research that relies on a predetermined search and analysis of literature materials to achieve the research objective. The process leads to the development of a clear summary of evidence-based literature or high quality (Mulrow, 1994).

Development of The Research Question

To have a clearly stated objective and research question, the study will rely on the PIO (Population, Intervention, Outcome) framework. The framework is usually used in healthcare research to effectively understand the underlying research variables within a study topic (White & Schmidt, 2005). The PIO framework can be used to determine the most suitable search terms and inclusion/exclusion criteria for the review. Thus, the following framework will be used to develop a research question for the proposed study:

Search Strategy

The study will conduct a comprehensive bibliographic search to identify journal articles and publications that are related to occupational therapy as an intervention for eating disorders. The bibliographic search will be conducted on electronic databases and search engines such as Google Scholar, EBSCO, MEDLINE and Proquest. These databases are specifically selected due to their abundance in peer-reviewed journal articles with research evidence (Khan, Kunz, Kleijnen, & Antes, 2003). Furthermore, the study has selected online search engines due to the efficiency of online processes compared to physical library search. Furthermore, online searchers are more replicable for future reference.

Search Terms

The study will rely on various search terms to facilitate a comprehensive search of literature materials from online databases. According to Ressing, Blettner, & Klug (2009), search terms are selected words, mostly derived from the main research variables, used in identifying relevant literature materials from online databases and search machines. Thus, some of the most relevant search terms that will be used in the proposed study include occupational therapy, food, diet, cooking, eating and disorders. The search terms will be used alongside the Medical Subjects Headings (MeSH) search engines to facilitate an automatic retrieval of relevant literature materials.

Boolean Operators

To effectively organize the search terms, the researcher will rely on Boolean Operators such as OR and AND. Ressing, Blettner, & Klug (2009) observed that Boolean operators help combine the search words to bring precision in the search process by incorporating sensitivity and precision in the process. For instance, in the proposed study, the researcher will use AND to combine unrelated words and narrow down the search process while OR will be used to combine unrelated words and broaden the search (Ressing, Blettner, & Klug, 2009).

Inclusion/exclusion criteria

In most cases, inclusion/exclusion criteria are used in specifying the relevance and scope of the literature materials retrieved for final review (Fattah, et al., 2013). Here, the researcher establishes certain characteristics that the studies must have to be admitted into the final review. All the other materials that do not satisfy these characteristics are excluded from the study (Ressing, Blettner, & Klug, 2009). Thus, in the proposed study, the researcher will include only the studies that are published in the English language so that the researcher can eliminate the risk of a language barrier when analyzing the data. Besides, the researcher will only include studies peer-reviewed academic papers, so that only the verified and valid data is gathered for analysis. Furthermore, only the studies that are retrievable in the full text will be included in the study, so that the researcher can comprehensively analyze the data.

Data Extraction

Upon searching and retrieving the most suitable journal articles from the search engines, the researcher will evaluate and extract specific information from each journal material to help with identifying their suitability and relevance to the study. Some of the information that the researcher will be keen to extract include the name of the authors, country of publication, the interventions, research methods, main findings and conclusion. These pieces of information will facilitate a quick analysis of whether each of the reviewed studies is suitable for the current research objectives.

Critical Appraisal

The researcher will not only extract data from the selected journal articles but also critically appraise them using the Critical Appraisal Skills Program (CASP). According to Ressing, Blettner, & Klug (2009), the CASP tool assists researchers to identify the relevance of each research article to their research questions. It also assists in measuring the strengths and weaknesses of the literature (Garg, Hackam, & Tonelli, 2008). In the proposed study, the researcher will use the CASP tool to evaluate the credibility of all the selected journal articles by establishing what the results are, whether the results are valid, and how the results apply to local practice (Garg, Hackam, & Tonelli, 2008).

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