Eating disorders: what should healthcare professionals know?

People with eating disorders are being repeatedly failed by the UK’s healthcare system, and this is partly due to a lack of training for healthcare professionals. Anorexia nervosa has the highest mortality rate of any mental disorder, with around one in 10 dying within 10 years of getting the disease, and one in five dying after 20 years.¹

Despite these alarming statistics, a lack of parity between child and adult services and poor coordination between those involved in treating patients means that people with eating disorders are being repeatedly failed by the UK’s healthcare system, according to The UK’s Health Ombudsman.²

The statement from the Ombudsman, which is published to coincide with Eating Disorder Awareness Week (27 February to 5 March), states that little progress has been made in eating disorder services since a report by the Parliamentary and Health Service Ombudsman (PHSO) was published six years ago.³

This is partly due to a lack of eating disorder training in medical schools. According to the charity BEAT, on average, UK medical schools provide less than two hours of eating disorder training, with one in five providing no teaching at all.⁴

While some progress has been made in improving this training, Tom Quinn, Beat’s Director of External Affairs says more needs to be done.

Over the last five years, failings in care have led to the deaths of at least 19 people with eating disorders. The Health Service Journal (HSJ), who led the investigation, found that these deaths could have been prevented if patient safety risks were properly analysed and healthcare professionals had better knowledge of eating disorders and how to treat them.⁵

Mr Quinn said it’s “appalling” that vulnerable patients are not getting the treatment that they desperately need and is calling on the NHS to expand training further.

“The government must ensure that all funding for eating disorder services reaches the frontline by holding local NHS leaders to account,” he said.

Recognising and treating eating disorders

There are various types of eating disorders that are clinically diagnosable. This includes anorexia nervosa (keeping weight as low as possible by strictly controlling food intake and/or exercising excessively), bulimia nervosa (binge eating followed by purging either by vomiting or using laxatives) and binge eating disorder (feeling compelled to overeat on a regular basis).⁶

However, people often present with eating disorder symptoms that do not completely match the clinical criteria for one of these three eating disorders. These patients may instead by diagnosed with an OFSED (other specified feeding or eating disorder).⁷

OFSED is the most common type of eating disorder and can develop from or into another diagnosis. It can present in multiple ways, and BEAT outlines some specific examples, including:

Atypical anorexia – when someone has the typical symptoms of anorexia but their weight remains in a normal range
Bulimia/binge eating disorder of low frequency and/or limited duration – when someone has all the symptoms of bulimia or binge eating but for a shorter period or time or less frequently than doctors would expect
Night eating syndrome – when someone repeatedly eats at night time, either after waking up from sleep or by eating a lot of food after their evening meal.

Avoidant restrictive food intake disorder (ARFID) is another type of eating disorder characterised by avoiding certain food and/or restricting intake in terms of overall amount eaten.⁸

ARFID may be caused by sensory issues (e.g. being sensitive to taste, texture, smell or appearance of certain foods), by distressing experiences with food which can cause fear or anxiety around certain foods or by low interest in eating and not recognising the signs of hunger.

BEAT notes that OFSED and ARFID are just as serious as anorexia, bulimia and binge eating disorder, and doctors must ensure they treat patients with these disorders with the same attention and care as they would with any other eating disorder.

NICE guidance recommends that if the GP thinks someone may have an eating disorder, they should immediately refer them to an eating disorder specialist for further assessment or treatment.⁹

Diagnosis is made by “taking a history”, which means talking to the person about their feelings towards food and how they behave around food. NICE notes that while screening tools such as SCOFF can be helpful, they should not be solely relied upon.

Healthcare professionals may also conduct some physical tests such as checking BMI, monitoring weight loss and performing blood tests. While many people with eating disorders may be reluctant to seek help, BEAT says that diagnosis is usually essential to be able to access treatment.

Treating eating disorders

Treatment for eating disorders should be individualised depending on which disorder the patient has and which symptoms they present with.

For example, NICE guidance states that for patients with anorexia nervosa, the key goal is to support the patient to reach a healthy body weight for their age, and this should be accompanied by psychological treatment such as eating-disorder-focused cognitive behavioural therapy (CBT‑ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) or specialist supportive clinical management (SSCM).¹⁰

How many sessions the patient needs will depend on individual circumstances but CBT‑ED programmes typically consist of 40 sessions over 40 weeks while MANTRA and SSCM typically consist of 20 sessions.

NICE says adults with binge-eating disorders and bulimia nervosa should be offered a guided self-help programme, if this is unsuccessful, they should be offered CBT-ED.

For people with OFSED, clinicians should use the treatments for the eating disorder it most closely resembles.

Healthcare professionals should also be aware that people with eating disorders are likely to present with other physical or mental health comorbities. These comorbidities should also be closely monitored and treated where necessary.

Health consequences of eating disorders

Eating disorders can have a variety of health effects, and can impact on the cardiovascular and gastrointestinal system, as well as having neurological and endocrinal affects.¹¹

Cardiovascular affects are among the most serious, and not consuming enough calories can cause the pulse to weaken and blood pressure to drop, increasing the risk of heart failure.

Food restriction and/or purging by vomiting can also cause gastrointestinal problems including stomach pain and bloating, blood sugar fluctuations, bacterial infections and constipation.

Constipation can be caused be inadequate nutritional intake or blocked intestines from solid masses of undigested food and weakened intestinal muscles which are unable to propel digested food along.

Extreme cases of binge eating can also cause the stomach to rupture while repeated purging by vomiting episodes can cause the oesophagus to rupture, both of which are life-threatening emergencies.

Neurological effects include difficulties sleeping, numbness and tingling in the hands, seizures and muscle cramps (due to a lack of electrolytes) and difficulty concentrating.

Restricted eating can also cause oestrogen, testosterone and thyroid hormones to drop. Without enough sex hormones, menstruation can stop and osteopenia and osteoporosis are more likely to develop over time.

In comparison, binge eating increases the risk of insulin resistance which can lead to type 2 diabetes. If binge eating leads to a person becoming overweight, they are also more likely to develop sleep apnoea which is linked to a higher risk of heart disease.

What are the other issues healthcare professionals need to be aware of?

Healthcare professionals should be aware that some symptoms of eating disorders can be mistaken for other conditions and vice versa.

There are also many disorders that are known to co-occur with anorexia nervosa, such as celiac disease, achalasia, illness anxiety disorder and body dysmorphic disorder.¹²

It is also important to remember that some people who appear physically fit and healthy may still be suffering with an eating disorder. For example, people with atypical anorexia may restrict their eating and/or excessively exercise yet remain a normal weight.

In such instances, it is important healthcare professionals look out for other warning signs, such as a slow heart rate. A slow heart rate is a sign of a malnourished heart and is often seen in people with eating disorders. However, a slow pulse is also seen in athletes who have strong, healthy hearts.¹⁰

Electrolyte imbalances can lead to irregular heartbeats and possibly heart failure and death. It is therefore important that healthcare professionals consider low heart rate and arrythmias to be a symptom of an eating disorder.¹³

Laxative misuse

Over-using laxatives is common in people with eating disorders as weight control method. However, misusing laxatives is not an effective weight loss method and can be extremely dangerous.

The National Eating Disorders Association (NEAD) states that most calories from food have been absorbed by the body by the time the laxatives act on the large intestine.¹⁴

Laxative use also causes dehydration and a loss of minerals and electrolytes. Electrolyte imbalances can lead to irregular heartbeats and possibly heart failure and death.

While weight may appear to drop immediately after a bowel movement, the weight will return as soon as the body rehydrates, the NEAD says. Dehydration can cause tremors, weakness, blurry vision, fainting and kidney damage. Severe dehydration may require medical treatment.

Laxative abuse can also damage nerve endings and leave the body dependent on them to have a bowel movement. This can lead to colon infections and irritable bowel syndrome (IBS), which can cause bloating and abdominal pain and cramping.

For laxative treatment to be effective, doctors, psychiatrists, psychologists, and registered dieticians should work together to provide a multidisciplinary treatment approach.

Close friends and family should also be asked to support people misusing laxatives and ensure they can talk openly about their anxieties and concerns to aid the recovery process.

Eating disorders and diabetes

According to Diabetes UK, eating disorders are twice as common in people with type 1 diabetes than people without the condition, with some estimates suggesting that up to 30% of people with type 1 diabetes have an eating disorder.¹⁵

This is because people with diabetes often focus more on their diet to control blood fats and blood pressure. People with type 1 diabetes are advised to eat foods which are lower in saturated fat, sugar and salt, and this can lead to an intense focus on food labels and calorie counting.

Diabetes UK highlights some signs of disordered eating in people with diabetes, including: increase in HbA1c or blood sugar levels that are going up and down a lot, going into diabetic ketoacidosis (DKA) or near DKA episodes, secrecy about diabetes management, trying to lose weight by restricting insulin and fear of hypos.

Type 1 diabetes with disordered eating is known as diabulimia. These patients will often reduce or stop taking insulin to lose weight or control their weight through food restriction and exercising excessively. The charity says this is extremely dangerous and can cause long-term damage, including blood vessel damage which can impact your feet, eyes and heart.¹⁵

Eating disorders in men

Healthcare professionals should also be aware that around one in four people with eating disorders are men. However, eating disorders are typically thought of as a ‘woman’s issue’, and this often leads to missed diagnoses and delayed treatment.¹⁶

Symptoms of an eating disorder may present differently in men compared to women, with men more likely to binge eat, compulsively exercise and ‘drive for muscularity’, with more of a focus on building muscle than achieving thinness.¹⁶

However, BEAT points out that these differing symptoms may be unhelpful and lead to gender stereotyping. “Not all men and boys with an eating disorder will feel driven to become more muscular. Everyone who experiences an eating disorder experiences it in a way that is unique to them,” the charity says.

This is why the theme of this year’s Eating Disorder Awareness Week is ‘Yes, men get eating disorders too’. As part of this campaign, BEAT launched the UK’s biggest survey to date on men’s experience with eating disorders.

It found that, of those surveyed, one in three had never accessed treatment, one in five had never spoken about their struggles and four in four felt raising awareness would help more men get treatment sooner.¹⁷

The NEAD states that the risk of mortality for males with eating disorders is higher than it is for females, and early intervention is therefore critical.¹⁸

The charity says healthcare professionals should take a “gender-sensitive approach” and recognise the different needs and dynamics at play. It also suggests creating an all-male treatment environment where possible as men and boys often feel out of place when predominantly surrounded by women.

Testosterone supplementation may also be needed in men and boys with anorexia nervosa to lower the risk of osteopenia and osteoporosis.

References

Anorexia Nervosa – Highest Mortality Rate of Any Mental Disorder: Why? Eating Disorder Hope. Available at: https://www.eatingdisorderhope.com/information/anorexia/anorexia-death-rate
Urgent action needed to prevent eating disorder deaths. Parliamentary and Health Service Ombudsman. Available at: https://phsombudsman-newsroom.prgloo.com/news/urgent-action-needed-to-prevent-eating-disorder-deaths
Ignoring the alarms: How NHS eating disorder services are failing patients. Parliamentary and Health Service Ombudsman. 2017. Available at: https://www.ombudsman.org.uk/publications/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients
Worth More Than 2 Hours. BEAT. Available at: https://www.beateatingdisorders.org.uk/support-our-work/campaign-for-beat/current/campaign-worth-more-than-2-hours/
Service in ‘very distressing’ state after 19 deaths. Health Service Journal. Available at: https://www.hsj.co.uk/mental-health/service-in-very-distressing-state-after-19-deaths/7034208.article
Overview – Eating disorders. NHS England. Available at: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/eating-disorders/overview/
OFSED. BEAT. Available at: https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/types/osfed/
ARFID. BEAT. Available at: https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/types/arfid/
Types of eating disorder. Beat. Available at: https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/types/
Eating disorders: recognition and treatment. NICE guideline [NG69] 2017. Available at: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations
Health consequences of eating disorders. The National Eating Disorders Association. Available at: https://www.nationaleatingdisorders.org/health-consequences
Five Disorders that Mimic Anorexia Nervosa. Center for Discovery: Eating Disorder Treatment. Available at: https://centerfordiscovery.com/blog/five-disorders-mimic-anorexia-nervosa/
Eating Disorders Hurt the Heart. Rosewood Centers for Eating Disorders. Available at: https://www.rosewoodranch.com/eating-disorders-hurt-heart/
Laxative abuse. The National Eating Disorders Association. Available at: https://www.nationaleatingdisorders.org/learn/general-information/laxative-abuse
I have type 1 diabetes – what can I eat? Diabetes UK. Available at: https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/i-have-type-1-diabetes
Do men get eating disorders? BEAT. Available at: https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/do-men-get-eating-disorders/
Eating Disorders Awareness Week. BEAT. Available at: https://edaw.beateatingdisorders.org.uk/
Eating Disorders in men and boys. The National Eating Disorders Association. Available at: https://www.nationaleatingdisorders.org/learn/general-information/research-on-males