International Journal of Qualitative Studies on Health
and Well-being
ISSN: (Print) 1748-2631 (Online) Journal homepage: https://www.tandfonline.com/loi/zqhw20
A new treatment for eating disorders combining
physical exercise and dietary therapy (the PED-t):
experiences from patients who dropped out
Maria Bakland, Jan H. Rosenvinge, Rolf Wynn, Venke Sørlie, Jorunn SundgotBorgen, Therese Fostervold Mathisen, Tove Aminda Hanssen, Franziska
Jensen, Kjersti Innjord & Gunn Pettersen
To cite this article: Maria Bakland, Jan H. Rosenvinge, Rolf Wynn, Venke Sørlie, Jorunn
Sundgot-Borgen, Therese Fostervold Mathisen, Tove Aminda Hanssen, Franziska Jensen,
Kjersti Innjord & Gunn Pettersen (2020) A new treatment for eating disorders combining
physical exercise and dietary therapy (the PED-t): experiences from patients who dropped out,
International Journal of Qualitative Studies on Health and Well-being, 15:1, 1731994, DOI:
10.1080/17482631.2020.1731994
To link to this article: https://doi.org/10.1080/17482631.2020.1731994
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INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING
2020, VOL. 15, 1731994
https://doi.org/10.1080/17482631.2020.1731994
A new treatment for eating disorders combining physical exercise and dietary
therapy (the PED-t): experiences from patients who dropped out
Maria Bakland a, Jan H. Rosenvingeb, Rolf Wynn c,d, Venke Sørliee, Jorunn Sundgot-Borgenf,
Therese Fostervold Mathiseng, Tove Aminda Hanssen a,h, Franziska Jenseni,j,k, Kjersti Innjordk
and Gunn Pettersena
a
Department of Health and Care Science, UiT - The Artic University of Norway, Tromsø, Norway; bDepartment of Psychology, UiT - The
Artic University of Norway, Tromsø, Norway; cDepartment of Clinical Medicine, UiT - The Artic University of Norway, Tromsø, Norway;
d
Division of Addictions and Mental Health, University Hospital of North Norway, Tromsø, Norway; eCenter for clinical nursing research,
Lovisenberg Deaconal University College, Oslo, Norway; fDepartment of Sports Medicine, Norwegian School of Sport Sciences, Oslo,
Norway; gFaculty of Health and Welfare,Østfold University College, Fredrikstad, Norway; hDepartment of Heart Disease, University
Hospital of North Norway, Tromsø, Norway; iDepartment of Language and Culture, UiT - The Artic University of Norway, Tromsø,
Norway; jDepartment of Education, UiT - The Artic University of Norway, Tromsø, Norway; kThe Eating Disorder Association “Spisfo”,
Tromsø, Norway
ABSTRACT
ARTICLE HISTORY
Purpose: Eating disorders (ED) are complex and severe illnesses where evidence-based treatment is needed to recover. However, about half of the patients with ED do not respond to
treatments currently available, which call for efforts to expand the portfolio of treatments. The
aim of this study was to explore experiences from patients who dropped out of a new treatment
for bulimia nervosa and binge ED, combining physical exercise and dietary therapy (PED-t).
Methods: We conducted open-ended face-to-face interviews. The interviews were transcribed verbatim and the data were analysed with a phenomenological hermeneutical
approach.
Results: Three themes emerged: “standing on the outside”, “unmet expectations” and “participation not a waste of time”. Feelings of standing on the outside were elicited by being
different from other group members and having challenges with sharing thoughts. Unmet
expectations were related to treatment content and intensity, as well as the development of
unhealthy thoughts and behaviours. Finally, some positive experiences were voiced.
Conclusion: A need to clarify pre-treatment expectations and refining criteria for treatment
suitability is indicated. The findings have contributed to the chain of clinical evidence
regarding the PED-t and may lead to treatment modifications improving the treatment and
thereby reducing drop out.
Accepted 13 February 2020
Introduction
Family-based therapy and cognitive-behavioural therapy (CBT) are recommended in several treatment
guidelines worldwide and appear as generally
accepted evidence-based treatments for eating disorders (ED). However, about half of the patients with ED
fail to respond to such treatments (Linardon & Wade,
2018; Wilson, Grilo, & Vitousek, 2007).
Considering the severity of ED, these findings call for
efforts to include new treatments in the portfolio of
evidence-based treatments. A second reason to increase
the portfolio of treatments refers to the diversity of
factors that maintain ED or that may help in the recovery
process. As far as general societal health is concerned,
new treatments should address the most prevalent EDs,
i.e., bulimia nervosa (BN) and binge eating disorder
(BED) (Rosenvinge & Pettersen, 2015).
CONTACT Maria Bakland
maria.bakland@uit.no
Langnes, Tromsø, 9037, Norway
KEYWORDS
Eating disorders; treatment;
qualitative analysis; patient
experiences; dropout
A new treatment for patients with BN and BED combining physical exercise and dietary therapy (PED-t) has
been developed (Mathisen et al., 2017). The PED-t rests
on a conceptual model positing the beneficial effects of
physical activity for improving mental health (Lubans
et al., 2016). Such effects are documented in the treatment of several mental illnesses, notably depression
(Josefsson, Lindwall, & Archer, 2014; Rosenbaum,
Tiedemann, & Ward, 2014) and anxiety (Jayakody,
Gunadasa, & Hosker, 2013). As for EDs, dietary consultations have promoted an early change in eating routines
and enhanced outcomes from established treatment
modules (Hsu et al., 2001; Painot, Jotterand, Kammer,
Fossati, & Golay, 2001), also for BN (Sundgot-Borgen,
Rosenvinge, Bahr, & Schneider, 2002). A randomized
controlled trial (RCT) conducted in Norway that framed
the present study has so far shown that the PED-t performs equally effective as CBT in alleviating BN and BED
Department of Health and Care Science, UiT - the Artic University of Norway, Postboks 6050
© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2
M. BAKLAND ET AL.
symptoms both immediately and at a one-year followup (Mathisen, 2018).
There may be a disparity between a statistically significant effect and the patients’ experiences of a given
treatment. This is an important reason why exploring
patients’ treatment experiences is generally recognized
as part of clinical evidence (Richards & Hallberg, 2015).
Accordingly, previous studies have explored treatment
experiences among the patients who completed the
PED-t (Bakland et al., 2019; Pettersen et al., 2017) as
well as their pre-treatment expectations (Pettersen
et al., 2019). No disparity was detected between the
statistically significant effects and their general positive
experiences. Overall, the PED-t stands out as helpful in
promoting recovery from BN and BED. Importantly,
patients’ experiences echoed the experiences reported
by the PED-t therapists (Bakland et al., 2018). However,
some patients wished a more flexible time-frame to
allow booster sessions, and voiced feelings of being
“different” in terms of age, interests or the nature of
their ED (Bakland et al., 2019; Pettersen et al., 2017).
These findings were congruent with previous studies
which explored treatment experiences with several
treatment approaches to ED (Krautter & Lock, 2004;
Lose et al., 2014; Money, Genders, Treasure, Schmidt, &
Tchanturia, 2011; Poulsen, Lunn, & Sandros, 2010;
Sánchez-Ortiz et al., 2011) in terms of overall positive
experiences, yet with suggestions for improvements.
In RCT studies, intention-to-treat analyses, as well as
dropout analyses, are important sources of knowledge
about treatment efficacy. Qualitative studies should follow the same kind of logic and explore experiences
among patients who drop out of treatment. Such studies are needed to capture more of the variety of experiences, and which may be under-reported in the
traditional treatment-satisfaction studies (Pettersen
et al., 2018). However, to our knowledge, no previous
qualitative studies have specifically addressed ED
patients who have dropped out of a treatment with
the intention to explore their treatment experiences.
To accommodate this need, the aim of the present
study was to explore the experiences of patients who
dropped out of the PED-t treatment.
Methods
Context and treatment
The study context was an RCT conducted between
2014–2016 that compared the PED-t treatment with CBT
(Mathisen et al., 2017). During 4 months, both treatments
were run in a 20-session group therapy format with 5–8
participants per group. The training programme in the
PED-t treatment consisted of three weekly exercise sessions, each lasting 40–60 min. Two sessions were resistance exercise, of which physical trainers supervised one.
The third session consisted of unsupervised interval
running. Following a traditional pyramid structure, the
running program comprised progressive interval periods
and active rest periods. The dietary therapy was led by
a dietician and included three psychoeducative modules
“dietary routines and structure” (five sessions), “nutritional
knowledge and practical skills” (12 sessions), and “summary and future plans” (three sessions). Further details
about the nature and rationale of the treatment are provided elsewhere (Mathisen et al., 2017; Pettersen et al.,
2018).
User advisory group
A user advisory group may improve the relevance and
quality of research (Oliver, Liabo, Stewart, & Rees,
2015). Accordingly, in the present study, two members from a national ED patient organization were
included. In regular meetings with the research
group, they shared their personal experiences with
ED treatment and contributed to the understanding
and analyses of the data as well as in the writing of
the present paper.
Participants
The principal investigator (JSB) contacted all 15 women
who did not complete at least 80% of the treatment,
with information about, and a request to participate in
the present study. Informed consent from five participants was returned to the first author (MB). Their age
ranged from 21 to 41 years. Three participants had BN,
two had BED, and four reported a history of anorexia
nervosa. One woman had children and lived with
a partner. Three of them were studying at the university
and two were employed. The women had completed
between 2 and 10 of the 20 treatment sessions in total.
Data collection
Face-to-face interviews were carried out at locations
of the participants’ choice. The interviewer had
a professional background as a nurse in the mental
health field and no prior relations to the participants.
Striving for openness towards the women’ experiences, they were encouraged to talk freely responding
to one open-ended question: Can you (as one of
those who left the PED-t) please tell me about your
experiences with participating in the treatment?
Follow-up questions were used to gain a deeper
understanding of areas that seemed essential for
each woman. The duration of the interviews ranged
between 1 and 1.5 h and they were not repeated. To
compensate for travel expenses and other costs, all
participants received a gift card of NOK 250 (approximately USD 32). The audio-recorded interviews were
transcribed verbatim.
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING
Data analysis
The consolidated criteria for reporting qualitative
research (COREQ) (Tong, Sainsbury, & Craig, 2007) were
used to promote explicit and comprehensive reporting of
the research data. We performed an inductive, three-step
data analysis inspired by a phenomenological hermeneutical approach and an interpretation theory of discourse
(Lindseth & Norberg, 2004; Ricœur, 1976). This approach
is suitable to explore lived experiences and involves
a dialectic movement between the parts of the text and
the text as a whole (Lindseth & Norberg, 2004). In the first
step, a repetitive, naïve reading of the whole text was
done to grasp an immediate understanding of the content and what it communicated. Next, a structural analysis
divided the text into meaning units based on sentences
or sections reflecting the research question and eventually themes disclosing meaning were formulated. The
third step involved a comprehensive understanding. Here,
the themes were summarized and reflected on in relation
to the aim and context of the study, the authors’ preunderstandings, the naïve reading of transcripts, the
structural analysis, and relevant literature (Lindseth &
Norberg, 2004). All authors continuously monitored and
discussed the analysis until consensus was reached about
how to best interpret the data.
Ethical considerations and data security
The RCT study was registered in the Clinical Trials registry (identifier: NCT02079935). The Norwegian Regional
Committee for Medical and Health Research Ethics
approved the present study (identifier: 2013/1871)
based on the Helsinki declaration of informed consent,
data security and the option to withdraw unconditionally upon request.
Results
Three themes emerged from the analysis, reflecting
experiences from those who dropped out from the
PED-t. The themes were “standing on the outside”,
“unmet expectations” and “participation not a waste of
time”. Each theme is presented below along with subthemes and illustrative quotations from the interviews.
Standing on the outside
Feeling different
A feeling of being different from other group members was evident, and the participants related their
feelings of being different to life in general, age,
interests, or being in other phases in terms of illness
severity and recovery. One woman who had been ill
for many years was afraid that the others’ inexperience would affect her benefits of participating:
3
I was the oldest and I have participated in treatment so
many times in the past. The other women had never
talked to anybody about their problem. I was afraid
that I would fall back into the position of being the one
who supports all the others (Participant 2).
A feeling of being different also emerged from listening to other participants talk about their overeating.
One woman said:
Maybe I was not in the right target group. The amounts
of food the other women talked about was unnatural
for me. What I believe is overeating, might not be
overeating after all (Participant 5).
Feeling different was furthermore related to previous
experiences with physical exercise. Some participants
were familiar with exercise and exercised daily before
starting the treatment, whilst others had never exercised on a regular basis. These differences affected
how the women experienced their benefit from participating in the treatment:
I had no problem talking to the other women, but they
were just so different from me in terms of eating and
exercising. I believe the treatment would have been
more beneficial if the women in my group shared my
interests, because then we might have talked about
something relevant to me (Participant 4).
Having challenges with sharing thoughts
This subtheme was related to a lack of group atmosphere allowing participants to share mutual experiences in one united conversation. Rather, group
discussions tended to evolve around one-to-one conversations between a group member and the therapist. In addition, some women occupied more time by
talking than the other group members:
Three of the others in my group took a lot of space.
Because of that, I often found myself in a listening
position. I had a lot to say but I was never able to
share my thoughts (Participant 1).
Perceived lack of experiences of exposing sensitive
issues to others could worsen the communication
with other group members:
When I came here for the first time, we sat down in
a circle to talk about ourselves. This was a bit sudden to
me, and I struggled and started crying. I dislike speaking
to a group like that and I returned home with
a headache (Participant 1).
Unmet expectations
Needing more treatment intensity and support
The need for higher intensity and more support was
generated from challenges in implementing the acquired
knowledge in their daily life. One such challenge was to
make good choices about meal compositions:
The dietary therapy was difficult because I had expected
it to be more specific. Food has always been an issue for
4
M. BAKLAND ET AL.
me and I felt that they did not go deep enough into the
details and left me with too many choices. I wished
there would have been a fixed plan for me to follow, on
what to eat and when (Participant 3).
Other kinds of challenges were to harmonize the
amount of foods and the level of physical exercise:
The therapists told me to exercise less and eat more.
I wanted to go all in and do this, but I felt I was not
receiving the support I needed. For me to be able to do
that, I would have needed to talk to the therapists
almost every day (Participant 4).
In addition, those who were unfamiliar with doing
physical exercise found it challenging to comply
with the exercise programme between each supervised treatment session:
There were too many days where I had to do everything
by myself. Gradually I realized that I needed a more
intensive treatment, like every other day. Then I might
have been able to develop some good routines. When
they asked me how I had done since we last met, I did
not want to answer because I had not done so well
(Participant 1).
Finally, unmet expectations were related to vague and
imprecise requirements from the therapists:
The therapists’ guidance and suggestions were too
vague for me. I need someone to be direct and strict,
explaining me that I need to do this for myself, and that
I need to work harder (Participant 3).
Lacking trust
Trusting the therapists’ advice seemed to be difficult
for the participants. For instance, the dietary advice
was experienced as too focused on rights and wrongs
with little room for flexibility. Another challenge was
believing in the sufficiency of the treatments exercise
programme. A fear of gaining weight challenged the
women’s ability to let go of their already established
routines;
I was extremely preoccupied with losing weight and did
not trust the advice they gave me. Of course, I was
afraid to gain weigh by giving away control. Eating
more and exercising less was not an alternative in my
mind (Participant 4).
Lack of trust was also related to the programme and
its rationale:
This experience has taught me that when you are ill
enough to let your eating disorder run your daily life,
you need something more than this treatment. Trying
to follow advice on an ideal amount of food and
exercise is not enough (Participant 5).
Lastly, lacking trust was experienced as the treatment
was run outside a health service institution, and by
therapists not obliged by a professional secrecy and
code of ethics:
I have never told anyone that I have an ED earlier. You
never know if they will keep their promise. I remember
having a moment when it was my turn to talk and so
I did. Afterwards I did not feel good about that. I guess
I never felt completely safe in the treatment setting
(Participant 5).
Developing unhealthy thoughts and behaviours
Unmet expectations were also generated by feelings
that the programme elicited unhealthy thoughts and
behaviours. The focus on nutrients and meals in the
dietary therapy was experienced as stressful, particularly for those with a history of anorexia nervosa, and
who had worked for a long time to eliminate such
a focus. Despite the therapists’ advice, the preoccupation of calorie counting revived;
I downloaded the calorie-counting app that I had used
on my phone earlier. I told myself that the app was not
dangerous in itself. That is how the ball started rolling.
Luckily, I was able to stop this unhealthy thinking early
enough (Participant 1).
Being weighed at each treatment session was also
challenging. Participants found themselves focusing
on the weight results, which in return, triggered
their weight and shape preoccupation;
We had to step on the weight each session, and
I questioned this because I had been strongly advised
the opposite when I was struggling with my anorexia.
I decided it became too much of an unhealthy focus for
me (Participant 1).
Finally, adding the treatments’ exercise programme
on top of one’s own daily exercise routine led to
a situation where one exercised too much. One
woman reflected around her experience in the following way:
For each treatment session, I felt that something was
wrong. I did not expect that the treatment would trigger my eating disorder, but I really became worse. I had
expected an easier process and developing a healthier
view on everything, but I ended up feeling a pressure to
perform (Participant 5).
Participation not a waste of time
Despite dropping out of the treatment, participants
also voiced positive experiences and feelings of having utilized the potentials of the programme. In particular, some knowledge and tools were acquired. For
example, it was beneficial to become more aware of
their ED problem. Furthermore, participants experienced that the programme was helpful in regulating
and normalizing the amount of physical exercise from
being excessive or just to start exercising. Finally,
there was a value in learning about the plate model
and various nutrients needed in order to stay healthy:
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING
I feel healthier now. I believe what I needed was some
time and space after the treatment to let the knowledge
mature. I still have days were I snap and eat too much,
but now I have learned something about what too
much really means (Participant 1).
Discussion
This study reports on views from patients who
dropped out from a new treatment for ED. Overall,
patients who dropped out from the PED-t treatment
experienced that they were different from other
group members and felt that they stood outside.
Important sources of such feelings were differences
in symptom load, age, interests and life in general, as
well as challenges with sharing thoughts. In addition,
these patients reported some unmet expectations in
terms of treatment content and intensity, and some
described developing an unhealthy preoccupation
with nutrients, physical exercise and weight. Finally,
the patients experienced having gained some knowledge and tools and making use of this knowledge
subsequently.
Feelings of standing on the outside are consistent
with a previous study (Bakland et al., 2018) from our
research group, and which explored experiences
among the therapists who provided the PED-t. They
reported that patients’ monopolization of group sessions jeopardized their efforts to create an including
group climate. Challenges in establishing a mutual
relationship between individuals in a treatment
group are, however, generic, and not confined to ED
or the PED-t (Hummelen, Wilberg, & Karterud, 2007)
or to patients who actually completed the PED-t
(Bakland et al., 2019). Such findings align with
a recent meta-analysis (Burlingame, McClendon, &
Yang, 2018) demonstrating that group cohesion contributes to outcomes across a variety of clinical conditions and therapeutic settings. Group-leaders in all
theoretical orientations are therefore encouraged to
foster cohesion. A further refinement of the PED-t
should consider a stronger focus on selection criteria.
A plea for more treatment sessions and follow-up is
a general finding which is also evident among other
patient groups (Hummelen et al., 2007; Kerkelä,
Jonsson, Lindwall, & Strand, 2015). However, the present
results point to more specified issues, like the need for
more support in implementing physical exercise and
new dietary routines, as well as more support in the
patients’ daily lives. Such issues align with other findings
showing that experienced treatment benefits are linked
to therapists’ availability and time to listen and understand the person behind the ED (Pettersen & Rosenvinge,
2002). In a further implementation of the PED-t program,
a stronger focus on pre-treatment patient expectations
may be important to address motivation.
5
The plea for more treatment sessions and therapist
support could easily be complied for in future use of
PED-t; however, the present study also revealed that
the patients experienced the treatment as timeconsuming and that the focus on nutrients and exercise caused stress. This aligns with previous findings
suggesting that an important reason why patients
drop out of treatment is to reduce the intensity of
the treatment (Nordheim et al., 2018). Again, this may
point to a need for discussing motivation for change
and pre-treatment expectations. Moreover, having
a history of anorexia nervosa seemed to have caused
extra challenges with regards to nutrients and being
weighted. This point reiterates the argument that the
future implementation of the PED-t may need
a stronger focus on treatment selection criteria. Such
a variety of patient experiences represent a challenge
when planning for treatments to fit individual needs.
A strength to this study is its originality in terms of
exploring treatment-experiences from ED patients who
have dropped out from a particular treatment. Adding
credibility to the findings is the fact that the interviewer
had no prior relation to the participants or in the developing and implementation of the PED-t. In addition, the
data analysis and interpretations were conducted with
a user involvement approach. A possible limitation was
the sample size. The fact that only five of the 15 eligible
patients were willing to participate may have restricted
the variety of experiences.
Conclusion
Our findings point to general challenges in developing
procedures to explore treatment suitability, as well as
capturing diversities between pre-treatment expectations and treatment content. Such procedures are relevant to promote general treatment effect factors like
treatment alliance and group cohesion. To include
experiences from patients who dropped out has
added variety to previous studies of patient experiences
with the PED-t treatment (Bakland et al., 2019; Pettersen
et al., 2017). Moreover, the findings have contributed to
the chain of clinical evidence of the PED-t and may lead
to important treatment modifications in order to
improve the treatment and thereby reduce drop out.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Maria Bakland is a PhD-student at Department of Health
and Care Science, UiT - The Artic University of Norway,
Tromsø, Norway. Her research focuses on eating disorder
treatment.
6
M. BAKLAND ET AL.
Jan H. Rosenvinge is a professor at the Department of
Psychology, UiT - The Artic University of Norway, Tromsø,
Norway. His research interests are within clinical psychology
and health psychology.
Rolf Wynn is a professor at the Department of Clinical
Medicine, UiT - The Artic University of Norway, Tromsø,
Norway and Division of Addictions and Mental Health,
University Hospital of North Norway, Tromsø, Norway. His
research focuses on e-health, health-services, health psychology and psychiatry.
Venke Sørlie is a professor emeritus at the Center for Clinical
Nursing Research, Lovisenberg Deaconal University College,
Oslo, Norway. Her research interests are within fear in children and youth with cancer, as well as dementia care and
existential needs and care.
Jorunn Sundgot-Borgen is a professor at the Department of
Sports Medicine, Norwegian School of Sport Sciences, Oslo,
Norway. Her research focuses on weight regulation, eating
disorders, menstrual irregularities and bone health.
Therese Fostervold Mathisen, PhD, is an associate professor
at the Faculty of Health and Welfare, Østfold University
College, Fredrikstad, Norway. Her research interests are
within eating disorders, physical activity and nutrition.
Tove Aminda Hanssen is a professor at the Department of
Health and Care Science, UiT - The Artic University of
Norway, Tromsø, Norway and Department of Heart
Disease, University Hospital of North Norway, Tromsø, Her
research focus on patient reported outcomes, complex
health interventions and nursing science.
Franziska Jensen is a PhD-student at the Department of
Language and Culture, UiT - The Artic University of
Norway, Tromsø, Norway, and Department of Education,
UiT - The Artic University of Norway, Tromsø, Norway. Her
research focuses on German as a foreign language and
topological field analysis. She is a member in The Eating
disorder Association “Spisfo”.
Kjersti Innjord is a member in The Eating disorder
Association “Spisfo” and have years of experience with
voluntary work in the local group.
Gunn Pettersen is a professor at the Department of Health
and Care Science, UiT - The Artic University of Norway,
Tromsø, Norway. Her research focuses on eating disorder
treatment, Public Health and rehabilitation, recovery in
mental health.
ORCID
Maria Bakland
http://orcid.org/0000-0002-4356-2586
Rolf Wynn
http://orcid.org/0000-0002-2254-3343
Tove Aminda Hanssen
http://orcid.org/0000-0003-31852364
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