Eating disorders [ED] can have devastating effects on the lives of young people and their families. The patient journey is isolating and often characterised by a lack of insight into their frailty. Sadly, EDs can be under-recognised and undertreated, with many opportunities to intervene missed. The mnemonic CARE (Consider, Ask, Risk assess, Everyone) may aid the recognition and risk assessment whilst encouraging holistic support of young people with eating disorders, and their families. This year new Medical Emergencies in Eating Disorders was published in the UK – take a look at our post to learn how you can incorporate this guidance into your practice.
1. Consider the diagnosis
Always consider the diagnosis of an ED in a young person with weight loss. They are common; a large systematic review of 94 studies from 2000-2018 estimated the lifetime prevalence of eating disorders to be around 8.4% for cisgender females and 2.2% for cisgender males. They are also prevalent amongst transgender young people. More than 50% of those affected go on to develop a chronic illness. The effect of the coronavirus pandemic on societies, families and individuals has worsened the prevalence and severity of EDs with a doubling in the number of both urgent and routine referrals in the UK.
EDs have the highest mortality of any psychiatric illness (from suicide or from medical complications). They are characterised by abnormal eating (dieting) or weight-control behaviours (purging, exercising) which can significantly impair social functioning. The physical effects of starvation affect all organs and are potentially life-threatening if not recognised and treated appropriately.
Presentation to EDs can be highly variable. For example, in cisgender males, the focus may be on being muscular, whilst in cisgender females, weight loss may be the primary goal. Transgender young people may experience distress with their bodies and engage in behaviours designed to accentuate the features of their desired gender. We must endeavour to ensure that EDs are diagnosed, and treatment offered to all young people affected.
Several factors may contribute to the difficulty in diagnosing EDs. They are often stigmatised making it difficult for young people to talk about them. Moreover, young people may feel that their weight loss is the only thing they are able to control, so can be unwilling to be open about it or engage in treatment to stop it. Many do not even view it as a problem and can present with non-eating related symptoms, such as syncope, amenorrhoea, fatigue, or constipation.
NICE recommends that diagnosis and referral occur at the earliest opportunity. The earlier the recognition the better chance of recovery.
2. Ask about eating issues
Communication with a young person with an ED has the potential to be particularly sensitive. There may be significant barriers to the patient opening up and accepting the concerns of their family and clinician.
The HEEADSSS assessment is a good place to start. This structure offers opportunities to establish rapport, engage with the young person and appreciate the eating issues within their wider social context. Here are some examples of questions that you could ask.
Does your weight or body shape cause you any stress?
Have there been any recent changes in your weight?
Does your weight affect the way you feel about yourself?
Have you ever done anything to try and manage your weight?
Tell me about your exercise regime.
Do you spend lots of time thinking about your weight and what you eat?
3. Risk Assess
Clinicians should undertake a comprehensive risk assessment for patients with a suspected eating disorder. The Junior MARSIPAN guidelines have been to risk-stratify patients. and these have now been incorporated into NICE NG69 guidance.
This includes measuring height and weight, calculating the BMI and % median BMI. Orthostatic blood pressure and heart rate measurements, an electrocardiogram and blood tests including electrolytes are also checked to assess for the physical effects of starvation. The presence of mental health problems associated with EDs should be screened for, including substance use and suicidality.
Young people may experience significant anxiety when having their weight taken. Ask them to step backwards on the scales (so that they can’t see their weight), after having a wee and first thing in the morning when possible. This “blind weighing” can help to decrease anxiety and improve treatment responsivity.
The red flags for same day acute hospital admission (as per the Junior MARSIPAN guidelines) are as follows:
– BMI <70% median BMI for age
– Weight loss >1kg/week
– Pulse < 40 bpm
– Blood pressure <80/60 mmHg
– Prolonged QTc
– Abnormal bloods (Hb <90, WCC < 2.0, K+ < 3.0, Glucose < 2.5, LFTS > 2 x normal)
There has been much public debate about people not receiving support services because their weight wasn’t low enough. The impact of the false reassurance of a single measure (such as BMI) can lead to a patient feeling dismissed, or, perversely, cause them to target that as a goal for their weight loss. Fortunately, NICE guidelines now explicitly state that a single measure such as BMI should not determine whether or not treatment should be offered.
4. Everyone is involved
It is essential to signpost families to support, as eating disorders can quickly take over the lives of patients and their families. Communication should be empathetic and compassionate as family members often feel guilty and responsible for the onset of the ED or not seeking help sooner.
When assessing the young person with a suspected ED, clinicians should find out what the family know about EDs. They can then provide education, and address misconceptions. Carers may also experience severe distress and may need treatment themselves. Holistic support should be offered, and the value of family-based therapy (FBT) is reflected in some of the NICE NG69 recommendations.
Several charitable organisations in the UK provide online support for patients and their families. Particularly useful ones are BEAT and SEED, both of which contain several free and easy-to-read leaflets.
It is always important to consider and screen for eating disorders. This should be done with empathy and sensitivity. Risk stratification and referral can be undertaken using Junior MARSIPAN and NICE NG69 guidance. Referrals should be made early and not delayed based solely on BMI or appearance.
Froreich, F.V., Ratcliffe, S.E. & Vartanian, L.R. Blind versus open weighing from an eating disorder patient perspective. J Eat Disord. 2020; 8: 39.
Galmiche M, Déchelotte P, Lambert G, et al. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutr.. 2019; 109(5), 1402-1413
Jones BA, Haycraft E, Murjan S, et al. Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. Int Rev Psychiatry. 2016;28(1):81-94.
Klein DA, Goldering JM, Adelman WP. HEEADSSS 3.0: the psychosocial interview for adolescents updated for a new century fueled by media. Contemp Pediatr 2014:1–16
Marikar D, Reynolds S, Moghraby OS. Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa). Archives of Disease in Childhood – Education and Practice 2016;101:140-143.
McKnight R, Boughton N. A patient’s journey. Anorexia nervosa. BMJ. 2009; 339 :b3800
NICE. Eating disorders: recognition and treatment. NICE guidelines [NG69]. 2020. Accessed online at www.nice.org.uk
Petkova H, Simic M, Nicholls D, et al. Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study. BMJ Open. 2019;9(10):e027339
Solmi F, Downs JL, Nicholls DE. COVID-19 and eating disorders in young people. Lancet Child Adolesc Health. 2021; 5(5): 316-318
Treasure J. A guide to the medical risk assessment for eating disorders. King’s College London; South London and Maudsley NHS Trust, 2012. Accessed online at https://www.kcl.ac.uk/academic-psychiatry/assets/guide-for-medical-risk-assessment-december-2012.pdf
Treasure J, Duarte TA, Schmidt U. Eating disorders. Lancet.2020; 395: 899 – 911
Thompson D. Top tips: eating disorders. Guidelines in practice. 2019. Accessed online at https://www.guidelinesinpractice.co.uk/eating-disorders/top-tips-eating-disorders/454613.article
Vitagliano JA, Jhe G, Milliren CE, et al. COVID-19 and eating disorder and mental health concerns in patients with eating disorders. J Eat Disord. 2021; 9: 80