by Annabel Gipp, a specialist mental health dietitian working with young people with eating disorders in York and Scarborough.
Eating disorder treatment is a specialised area of dietetics that requires in-depth knowledge and understanding to treat. However, it is likely that a dietitian working in any area will meet a patient experiencing an eating disorder. Here, are some answers to questions about working in the field of eating disorders.
“It is therefore vital that each person with disordered eating is considered as an individual, and personalised treatment plans are established to address the underlying multiple factors leading to the current problem.”
Q. What types of eating disorder exist and how common are they?
The most well-known eating disorders are anorexia nervosa (AN), which is characterised by extreme weight loss, resistance to eating and perception of being overweight; and bulimia nervosa, which is characterised by binging and purging episodes most commonly through self-induced vomiting.
However, it is reported that anorexia and bulimia may only account for 50% of eating disorder cases (1 - see references below). Other disorders include binge-eating disorder in which a person binges but does not then ‘purge’ or Avoidant or Restrictive Food Intake Disorder (ARFID). This was previously known as Eating Disorder Not Otherwise Specified. ARFID is commonly linked to distress or trauma, and a severe restriction of types of food that are willing to be eaten. It differs from AN in that the person with the disorder often will not perceive themselves as fat or want to lose weight. This disorder is commonly associated with autism, although it is important to note that in all eating disorders, comorbidities such as depression, anxiety, OCD, selfharm, suicidality or other mental health difficulties are often present (2).
Eating disorders affect 1.6 million people in the UK; 11% are male. Most commonly affected are adolescent women, although the age range of ‘adolescent’ varies between 14-25 and 13-17 years old, depending on which guidelines are used (1,2). It is advisable that signs and symptoms of nascent eating disorders developing in girls of these age ranges are particularly closely monitored, due to their increased risk of developing these disorders (2).
Q. What are the risk factors or causes of developing an eating disorder?
There is rarely a simple answer to this question, as the development of eating disorders includes a wide range of complex interplaying genetic, social and environmental factors. Within eating disorder assessment, the multi-disciplinary team will conduct a full psychological formulation, of which it is important for dietitians to be a part of. These factors can include genetic vulnerability (family history of eating disorders), perfectionism, traumatic events such as bullying or bereavement, body dissatisfaction, peer pressure, poor nutritional knowledge and negative social media exposure.
Research has not been able to identify one causal or dominant risk factor. In recent twin studies, non-shared environmental risk factors combined with genetic factors positively predicted risk of developing eating disordered behaviour rather than either factor independently, and no individual risk factor was seen to be a sole cause of developing an eating disorder (3). It is therefore vital that each person with disordered eating is considered as an individual, and personalised treatment plans are established to address the underlying multiple factors leading to the current problem.
Q. Where should people with eating disorders be treated?
It is essential that people with eating disorders are treated by a trained specialist multi-disciplinary team that includes psychologists, psychiatrists, mental health nurses and trained AHPs such as dietitians. These teams work in a variety of settings, including outpatient mental health services, specialist hospitals, day centres and outreach teams for both adults and paediatric patients (4,5).
However, people with an emerging eating disorder may not initially present to specialist services, so it is essential that anyone is able to recognise and respond to concerns or indications that an eating disorder may be present. Often, the person’s management of other conditions such as diabetes, irritable bowel disease or allergies will decrease when an eating disorder develops, which may prompt them to be seen in general clinics (2).
Q. How do you identify an eating disorder in a general setting?
It is no longer advised to use a single reference measure, such as BMI or a questionnaire, to identify the presence of an eating disorder. Instead, look at a variety of the signs and symptoms. It must always be considered that an eating disorder, although more common in certain parts of the population, can affect anyone regardless of age, gender, culture, socioeconomic status or health. It is also known that people with an eating disorder may find it difficult to talk about their anxieties regarding food and eating.
If you have concerns, it is advised to be fully open and transparent regarding these and what further steps are needed to address them. It is also important to be aware of what further support is available in your area, for example, who your specialist teams are, where they are located and how to refer. These teams can also be a wealth of support and information if you are unsure what to do next.
It is generally advised, that if you suspect an eating disorder, to ascertain the person’s current BMI, recent weight history, blood results, recent ECG and any further concerns you have regarding dietary patterns, mental health and social withdrawal. This will help the specialist team in prioritising the referral. Always be aware of the distress and emotional state of the person and their family at this time and ensure they are fully aware of what you are communicating with the specialist team (2).
Q. How quickly can people with eating disorders be seen?
It is vital that people with a suspected eating disorder are seen as quickly as possible as this improves longterm prognosis. Access and waiting time standards were released by NHS England in 2015 which advised that children and young people with a suspected eating disorder should be seen within four weeks for routine and within one week for urgent cases.6 However, there is no such guideline currently in place for adult services and the UK’s leading eating disorder charity Beat is running a campaign to urge the government to ‘End the Wait’ and introduce similar standards for adult services.
Even though there is no current guideline in place, it is still advised that adults are assessed by specialist services as quickly as possible, making the identification of early eating disorders vital.
Q. How should these patients be treated in acute hospitals, particularly regarding refeeding?
It is not expected that an acute ward will be able to treat the underlying eating disorder for either a child or adult. A person with an eating disorder may be admitted due to concerns with their physical health, potentially refeeding risk, postural drop, or syncope, and this should be the treatment priority for the ward. The local mental health team should also be involved to support the service-user throughout their hospital stay and to establish continued treatment, once discharged, either at home or in a specialist hospital setting.
Management of refeeding on an acute ward may be challenging due to the person’s fear of consuming food, and there is often little or no negotiation in the nutrition being provided. It is often safest to use prescribed nutritional supplements, or nasogastric feeding if oral supplements are refused, to safely manage refeeding risk. Solid food should be quickly reintroduced after refeeding risk is resolved (4). If a patient however refuses all food and fluid, a Mental Health Act assessment may be recommended and treatment in the best interest of the patient advised. This is often highly distressing so all other options should be considered prior to this.
Particularly in low-weight patients, it may be challenging to manage high risks of refeeding syndrome based on weight, for example, a 32kg individual at 5-10kcal/kg would be given only 160- 320kcal per day. This is particularly true for paediatric patients who may have very low weights. Therefore it is advised that the starting intake should not be lower than intake prior to admission, and for paediatrics, starting at 20kcal/kg or higher appears to be safe, increasing by 200kcal per day with constant monitoring of refeeding markers (5).
Further and more detailed advice on the management of patients in inpatient settings is available in the MARSIPAN and Junior MARSIPAN Guidelines in the reference list.
Q. Are there any courses available to learn more about eating disorders?
A good place to start is the Introduction to Mental Health training offered by the BDA. In addition to this, the BDA’s Mental Health Specialist Group has many online resources available and holds an AGM learning event which can be attended by any members of the group. There are also many courses and resources for both health professionals and patients on the Beat website.
References
1. The Priory Group. Eating Disorder Statistics. Accessed 09/10/18.
2. NICE (2017) Eating Disorders: Recognition and Treatment (NG69)
3. Culbert K M, Racine S E & Klump K L (2015) Research Review: What we have learned about the causes of eating disordersa synthesis of sociocultural, psychological and biological research. The Journal of Child Psychology and Psychiatry. 56:11
