An overview of eating disorders and the risks they pose is presented in this article, along with details of new guidance on recognising and managing medical emergencies in people with eating disorders. This is a Journal Club article and comes with a handout that you can download and distribute for a journal club discussion.
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Abstract
Eating disorders are defined by abnormal eating behaviours and associated feelings and thoughts. They are serious illnesses and can prove fatal. The dangers of anorexia nervosa are commonly recognised, but it is important to acknowledge that other eating disorders also have a high risk of mortality. The Royal College of Psychiatrists has published guidance on recognising and managing medical emergencies in eating disorders, which replaces older guidance focused solely on anorexia nervosa. This article sets out to increase professional awareness of the different types of eating disorders and the risks they pose, and how the guidance can help facilitate safer and better patient outcomes.
Citation: Salmon J, Austin K (2023) Adopting new guidance in recognising and managing eating disorders. Nursing Times [online]; 119: 5.
Authors: Joe Salmon is mental health nurse, Kayleigh Austin is adult nurse practising as a portfolio delivery lead; both at Southern Health NHS Foundation Trust.
Introduction
Eating disorders are “serious and often fatal illnesses that are associated with severe disturbances in people’s eating behaviours and related thoughts and emotions” (National Institute of Mental Health (NIMH), 2023). Regardless of age, gender, culture or racial background, anyone can develop an eating disorder (Rethink Mental Illness, nd), and it is well established that people with eating disorders have high mortality rates: mortality rates for those diagnosed in hospital settings are five to seven times higher than those documented for the general population (Iwajomo et al, 2021).
Some health conditions may increase people’s risk of developing an eating disorder; for example, having type 1 diabetes can have biological and psychological implications that can lead to a higher risk of developing an eating disorder (Beat, nda). Adolescents and young adults with type 1 diabetes and eating disorders have more than three times the risk of diabetic ketoacidosis and nearly a sixfold increase in mortality risk compared with their insulin dependent peers who do not have an eating disorder (Gibbings et al, 2021).
Anorexia, bulimia and binge eating disorder (BED) can reduce the number of years a person spends in good health due to delayed recovery and persistence of partial/full eating disorder pathology (van Hoeken and Hoek, 2020). From 2007 to 2017, the number of years people with anorexia and bulimia live with disability increased, despite decreasing over the same period for people with other mental disorders (van Hoeken and Hoek, 2020). Although treatments for bulimia and anorexia have progressed, mortality rates remain high and, even for people treated outside of hospital, are still around twice those of people without an eating disorder (van Hoeken and Hoek, 2020).
Salmon (2022) highlighted that health professionals in all settings should have an awareness of anorexia nervosa and be prepared to intervene early. This has since broadened to include all eating disorders, with new guidance from the Royal College of Psychiatrists (2022) on recognising and managing medical emergencies in eating disorders (MEED) aiming to make preventable deaths from any eating disorder a thing of the past. MEED replaces the College’s MARSIPAN and Junior MARSIPAN guidance, which focused exclusively on anorexia nervosa; all nurses and other health professionals should be aware of it.
The aim of this discussion is not to provide a comprehensive explanation of the cause and treatment of eating disorders, but rather to guide better care for improved patient outcomes by promoting awareness of the MEED guidance and other eating disorders not often discussed.
Types of eating disorders
Most people with eating disorders display common traits that are shared between different subtypes, such as the inability to eat certain food groups or fluctuations in weight (Salmon, 2022). Being able to recognise the different subtypes is important, as other eating disorders can be just as dangerous as anorexia nervosa, which was the focus of MARSIPAN guidance (Royal College of Psychiatrists, 2022).
Anorexia nervosa
Anorexia nervosa, also known simply as anorexia, is characterised by:
Extreme fear of weight gain;
Hunger denial;
Fixation with food preparation;
Weight loss;
Difficulties maintaining an appropriate body weight for height, age and stature;
Sometimes a distorted body image;
A restricted calorie and dietary intake (National Eating Disorders Association (NEDA), nda).
A patient with anorexia may be very focused on food and/or exercise, and present as needing to control these aspects of their life (Mind, 2021).
Figures from 2019 indicate that total mortality for anorexia alone is 15 deaths per year (Office for National Statistics, 2021).
Bulimia nervosa
Bulimia nervosa, also known as bulimia, is characterised by:
Often a normal or above average body weight;
Recurrent episodes of binge eating;
Odd eating habits or rituals;
Self-induced vomiting;
Inappropriate use of laxatives or diuretics;
Excessive exercise (Johns Hopkins Medicine, nd).
Beat (ndb) defines people with bulimia as being “caught in a cycle of eating large quantities of food (called bingeing), and then trying to compensate for that overeating by vomiting, taking laxatives or diuretics, fasting, or exercising excessively (called purging)”. As with anorexia, individuals may also have negative feelings about themselves and their appearance (Mind, 2021).
Those with bulimia, even if not underweight, can also present in lifethreatening emergencies due to medical complications such as electrolyte disturbances and gastrointestinal complications (Royal College of Psychiatrists, 2022).
Binge eating disorder
BED is characterised by individuals eating:
More quickly than usual;
Large amounts of food until they feel uncomfortably full;
When they don’t feel physically hungry;
Usually alone due embarrassment at the amount they eat.
Binges can be planned in advance or may be spontaneous (Beat, ndc). A sense of loss of control, as well as feelings of guilt and shame after a binge, are not uncommon (Beat, ndc; NEDA, ndb; NHS, 2020).
BED can also lead to increased acid reflux, irritable bowel syndrome and, due to increased weight, joint and muscle pain (Mind, 2021). Data on mortality for BED is limited, but there are several co-occurring conditions, such as obesity, type 2 diabetes and hypertension (Keski-Rahkonen, 2021).
Other specified feeding or eating disorder (OSFED)
OSFED is a diagnosis in which a person’s symptomology does not precisely fit or align with another eating disorder, which is a relatively common occurrence. OSFED is an umbrella term and, as with other eating disorders, it may not be immediately obvious to others that the person is experiencing ill health (Beat ndd). One example is diabulima (one of many OSFEDs); this is not an official diagnosis, but a term specifically related to an eating disorder that only affects individuals who have type 1 diabetes. These patients intentionally reduce or omit insulin to control calorie intake and gut absorption of food (Mind, 2021).
Avoidant restrictive food intake disorder (ARFID)
ARFID is similar to anorexia nervosa in that it involves limiting the amount and/or the type of food that is consumed. Conversely, however, ARFID does not involve stress about body shape, size or fear of fatness (NEDA, ndc). Possible reasons for ARFID can include negative emotions over the texture or smell of particular foods (NHS, 2021). The avoidance of specific foods can result in decreased nutritional intake, leading to nutritional deficiencies and, potentially, hospitalisation (Feillet et al, 2019).
“People with eating disorders can be extremely persuasive and articulate, and may convince emergency department staff to allow them to go home, despite the risks the individual presents”
The need for better management of eating disorders
Eating disorders are “prevalent, potentially lethal and treatable, yet remain underprioritised within clinical care, research and policy”; however, every clinician should be accustomed to identifying and handling them (Nicholls and Becker, 2020). Despite UK clinicians spending 10-16 years in undergraduate and postgraduate training, they receive less than two hours’ eating disorders teaching at medical school (Ayton and Ibrahim, 2018).
Children and young people’s waiting times for eating disorder treatment in the UK have reached record levels as services struggle to meet overwhelming demand: only 61% of patients started urgent treatment within one week of diagnosis in the first quarter of 2020-21, which is the lowest proportion since 2016-17, and just 73% of patients started routine treatment within four weeks in the first quarter of 2021-22, down from 87% in the previous year (Iacobucci, 2021).
It can be extremely hard for those with an eating disorder to seek help, and yet a survey by Beat (nde) showed that, when help had been sought from a GP, 58% felt their GP did not understand eating disorders and 92% felt that GPs would benefit from additional training about eating disorders. As GPs are often the first point of contact for those seeking help with an eating disorder, they need a good understanding of these illnesses and how, when and where to refer patients for specialist help (Parliamentary and Health Service Ombudsman (PHSO), 2017).
Early detection of eating disorders may decrease mortality and prevent the risk of evolution towards somatic, psychiatric and psychosocial complications (Kalindjian et al, 2022). However, Beat’s (nde) survey highlighted many missed opportunities for early intervention.
Effect of Covid-19
It is uncertain how the Covid-19 pandemic has affected young people with eating disorder behaviours, such as purging and binge eating (Solmi et al, 2021). Linardon et al’s (2022) scoping review of 70 papers on eating disorders and Covid-19 found that, despite variability in estimates across studies, eating disorder symptom severity and incidents of probable diagnoses appeared elevated during the pandemic. There was also evidence of an increase in demand for eating disorder services during the pandemic, due to factors such as restrictions to daily activities, isolation and the threat of food shortages (Linardon et al, 2022). This suggests that, to provide safe and appropriate care for this patient group, health professionals need an even greater awareness of eating disorders and evidence based guidelines on their treatment and management.
The new guidance
Background
The PHSO’s (2017) report highlighted the urgent need to improve the management of eating disorders. This followed the death in 2012 of 19 year old Averil Hart, who had anorexia and whose death was found to have been avoidable. Several NHS organisations had missed opportunities to prevent her deterioration, which led to her final admission to hospital, where she died.
Unfortunately, this was not an isolated case and the PHSO also investigated further deaths in its report. A woman who was severely ill died from a heart attack, triggered by starvation due to her anorexia, after being discharged from hospital with an inadequate care plan. Another, with a history of vomiting and binge eating, was referred to an eating disorder service that was short staffed. She deteriorated with no care plan and died of heart failure following an overdose.
The PHSO (2017) report highlighted five areas for service improvement, including identifying gaps in training for health practitioners, reviewing the quality and availability of adult eating disorder services and ensuring learning from safety incidents.
How MEED differs from MARSIPAN
The shift from MARSIPAN to MEED guidance was in response to feedback from patient and carer groups highlighting the medical risks for all eating disorders (Royal College of Psychiatrists, 2022). MEED guidance states that, although not all eating disorder deaths are avoidable, psychiatric and medical services need to do more to improve the care of patients who are severely ill, as all eating disorders, not just anorexia nervosa, can result in high – and likely preventable – mortality (Royal College of Psychiatrists, 2022).
In replacing MARSIPAN guidelines, MEED has the potential to improve patient outcomes and change perceptions of all eating disorder needs but staff need to familiarise themselves with it and promote it in all settings. Below is a summary of what it covers and how it differs from the MARSIPAN guidelines:
MARSIPAN focused on anorexia nervosa but MEED also covers the risks of other eating disorders, including bulimia nervosa, ARFID and BED;
Previously, MARSIPAN and Junior MARSIPAN were created to differentiate between adults and children, but MEED combines guidance on adult, child and adolescent care to try and reduce confusion around transition ages and redress potential disparities in approach;
Due to an overall shortage of eating disorder beds in the UK, >100 patients have been transferred from England to Scotland for treatment since 2017 (Marsh, 2022). MEED recommends that, when specialist eating disorder unit (SEDU) beds are unavailable, general psychiatric units should be supported to provide specialist eating disorder care;
When a SEDU is required but unavailable, a choice must be made between a medical and general psychiatric unit without specialist eating disorder bed (SEDB) services. This should consider factors such as the experience of the general psychiatric unit in managing malnutrition and the quality of liaison between the medical team and the eating disorder service;
Admission to medical wards should not be prolonged and eating disorder services need to try to facilitate discharge back to community care or transfer to a SEDU or SEDB.
Presentation in the emergency department (ED)
Fewer people present in the ED with an eating disorder than with other psychiatric conditions; this can lead to missed diagnoses of eating disorders, despite their high medical risk and mortality rates (Jafar et al, 2021). When ED health practitioners suspect an eating disorder, they should follow the checklist of ‘lightbulb’ signs for increased severity of presentation in Table 3 of the MEED guidance, allowing a risk assessment to be undertaken. Table 1 shows some possible presentations and symptoms in people with an eating disorder. These are adapted from the MEED guidance, but should not be used as a substitute for the official checklists, which give more-detailed and instructive guidance for professionals.
It is important to note that people with eating disorders can be in denial of their presentation (Royal College of Psychiatrists, 2022) and collateral history from parents, caregivers/friends and electronic health records or the GP, is key. The MEED guidance also has a detailed all age risk assessment framework for assessing risk to life (Table 1 in the guidance), which includes a traffic light system to help. Its use in acute hospitals has the potential to save lives as it provides clarity for professionals who may not be familiar with the risks, especially if this is an uncommon presentation.
Professionals must also test mental capacity, which is often a subjective judgement. However, those with an eating disorder, despite sometimes being very unwell, can be assessed as capacitous by those unfamiliar with this patient population (Royal College of Psychiatrists, 2022). Staff must be aware that people with eating disorders can be extremely persuasive and articulate, and may convince ED staff to allow them to go home, despite the risks the individual presents (Royal College of Psychiatrists, 2022).
If there is an immediate risk to life due to acute deterioration, or any danger of acute decline, staff need to act decisively in the best interests of the patient. They also need to document the type and severity of risk, and the best interest decision and action to reduce risk and preserve life that is being undertaken (Royal College of Psychiatrists, 2022). Fig 1 shows a basic flowchart outlining a decision making process staff could use in the ED.
Presentation in primary care
A GP or other primary care professional may be the first to see an individual with an eating disorder. Primary care practitioners play a vital role in engaging with the individual and referring them to specialist care (Royal College of Psychiatrists, 2022). As severe cases of anorexia nervosa are rare in the primary care setting, there is a risk of delayed recognition and the Royal College of Psychiatrists (2022) recommends that when GPs suspect an eating disorder, they should discuss the case with an eating disorders/liaison psychiatry clinician. When a primary care practitioner does suspect an eating disorder, they should follow the checklist in MEED (Table 3 in the guidance) allowing a risk assessment to be undertaken. Some of these presentations in the checklist are summarised in Table 1.
Managing symptomology
Patients with an eating disorder may present at primary or secondary sites with one, or a combination, of the signs and symptoms listed in the MEED guidance, some of which are summarised in Table 1. It will be down to the clinician’s ability to gain an accurate account of the patient’s history and make observations to enable identification of an eating disorder if this is the patient’s first presentation.
If a patient has a known past medical history of eating disorders or is under the care of an eating disorder service, some of the symptoms outlined in the MEED guidance may serve as red flags that indicate that the treatment plan needs to be reviewed urgently.
Associated risks and management
Eating disorders have high rates of medical complications and associated risks, ranging from electrolyte disturbances to cardiac abnormalities (Jafar et al, 2021). Despite their complex nature, eating disorders can be further complicated by other disorders including, but not limited to:
Post-traumatic stress disorder;
Personality disorders;
Factitious disorders;
Functional syndromes (Royal College of Psychiatrists, 2022).
One-fifth of patients with an eating disorder have a lifetime diagnosis of obsessive compulsive disorder (Mandelli et al, 2020), and those with eating disorders also have a high prevalence of substance use disorder (Bahji et al, 2019). To help maintain consistent care with patients who have an eating disorder, a structured approach to treatment is needed, which includes good documentation of plans and any restrictions; this may help avoid disagreements between patients, staff and family members (Royal College of Psychiatrists, 2022).
It is vital that medical and psychiatric staff are aware that, despite appearing well and having normal blood parameters, those with an eating disorder admitted to a medical ward may be at high risk of mortality (Royal College of Psychiatrists, 2022). Soon after admission, a scheduled meeting should take place with key personnel to decide how to achieve treatment aims, and the medical team must be fully supported by the psychiatric team (Royal College of Psychiatrists, 2022). The key to good care is an integrated approach, with trust and cooperation between commissioning bodies, liaison psychiatry, primary care, specialist ED staff and medical specialties (Royal College of Psychiatrists, 2022).
Conclusion
The MEED guidance is welcome and shows how the Royal College of Psychiatrists is dedicated to helping reduce the number of preventable deaths in people who have an eating disorder. However, as health practitioners, we must do more. This article is not a substitute for reading the MEED guidance, but will hopefully inspire health professionals to update their knowledge for the benefit of their patients.
Let us stop preventable deaths and learn the lessons from past negative experiences and tragedies. Minimal preventable deaths in patients with an eating disorder should not just be an aim, it must be a gold standard – and it is a gold standard we will only achieve if we all commit to bettering our practice.
Key points
All eating disorders, not just anorexia nervosa, can result in high, and often preventable, mortality
Health practitioners in all settings must be able to recognise and manage medical emergencies in people with eating disorders
New guidance on medical emergencies in eating disorders aims to improve patient outcomes and change perceptions of eating disorder needs
Minimal preventable deaths in patients with an eating disorder should not be an aim, but a gold standard
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