Practice nursing is a profession at the forefront of primary care and throughout the pandemic it has been reported widely that eating disorders are on the increase or that those with existing eating disorders are relapsing at a higher rate (Zipfel et al, 2022). With the lack of support the pandemic produced through the restriction of face-to-face services and other community-led or charity-based services for the sake of meeting lockdown requirements and restrictions, a heavy price has been paid with devastating consequences for many. We have a chance to make a difference before any further deterioration can happen – if a proactive approach is taken with quick attention to the hidden red flags the patient exhibits, help can be given. Bulimia, anorexia and binge eating are difficult to discuss for the patient, so the key is in how the practitioner approaches the topic when they notice either signs or symptoms that may be part of what the patient has come in with or aspects of their condition that the patient is trying to keep hidden: they may not be ready to face the damage being done to their body or they may have comorbid mental health issues that make it more difficult for them to recognise their problem. Body dysmorphia is a common issue throughout the eating disorder spectrum. Ultimately with the right approach, the patient may feel ready at the point of seeing you to be referred to the eating disorder team, or the patient may require several appointments – or counselling at first – to help them get to a position where they are ready to take on the complex task of managing their eating disorder.
Facts and figures
The UK's leading charity for eating disorders, Beat, estimates that there are about 1.25 million people in the UK with an eating disorder, and 75% of those are women (Beat, 2022). They also commented on figures from the Health and Care Information Centre that showed an 8% rise in eating disorders in the 12 months prior to October 2013 (Beat, 2022). This is likely to have risen not just across the board but perhaps in certain sectors of society that were hit the hardest by the pandemic, as stress can be a trigger. Since 2005 there has been a huge increase in admissions for eating disorders, up by one third (Beat, 2022). This could be that more are seeking help or that eating disorders are being recognised and dealt with more often rather than going unnoticed. The stigma associated with having an eating disorder and the fact someone may fear it is impossible to change their eating or routine mean that many people go undiagnosed. Statistics regarding prevalence are therefore not necessarily accurate. The charity states a study in 2017 that found anorexia accounted for 8% of all eating disroder diagnoses, avoidant/restrictive food intake disorder (ARFID) accounted for 5%, binge eating 22%, bulimia 19%, and 47% of cases were classified as ‘other specified feeding or eating disorder’ (OSFED).
It is well documented that cases often develop earlier in life, but it should not be forgotten that many people still develop these disorders later in life. It is important to not unconsciously discriminate when considering someone's potential diagnosis for an eating disorder in terms of age, as Beat (2022) explains many people are likely to not have an appropriate diagnosis due to being outside of the stereotypical age bracket, thus leading to poorer outcomes. The average recovery time from anorexia is 8 years, and 5 years for bulimia, although severe cases can endure for many more years (Beat, 2022). This is why it is essential that an earlier diagnosis is made, to give the best chance possible for the patient.
In terms of recovery, a patient may not feel it is possible, but that is where we can reassure that it can be overcome. Beat (2022) reports that research suggests 46% of anorexia patients make a full recovery, with 33% showing improvement; however, 20% were documented as remaining chronically ill. In total, 45% of people suffering with bulimia are estimated to make a full recovery, and 27% improve considerably; however, similarly to anorexia, 23% are documented to suffer chronically.
Of all the psychiatric illnesses, anorexia has the highest mortality rate (Beat, 2022), because of the medical complications associated with the condition, as well as suicide. Bulimia is also associated with severe medical complications, and binge eating disorder sufferers often experience medical complications associated with obesity. It is essential to have an awareness of this often hidden illness with devastating consequences. Medical complications involve damage to the oesophagus leading to a high rate of cancer for people with bulimia, and multiple organ failure for people with anorexia due to starvation over a prolonged period of time. Other complications can happen such as aspiration pneumonia and arrhythmias due to loss of potassium for bulimia, with similar electrolyte problems for those with anorexia. Obesity caused by binge eating is associated with diabetes and heart disease – two of the biggest killers in the western world. It is evident that every eating disorder case is very serious, being something health professionals need to maintain an awareness of and act promptly when they see the signs and symptoms.
Assessment of the signs and symptoms
One of the key misunderstandings is that those with anorexia are extremely thin, when in actual fact they may not be obviously emaciated by their condition. Also, it is easy to forget the existence of other eating disorders as often they are not as easy to notice – being in average weight or overweight people.
‘Of all the psychiatric illnesses, anorexia has the highest mortality rate, because of the medical complications associated with the condition, as well as suicide.’
Professor John Morgan at Leeds Partnership NHS Foundation Trust designed the SCOFF screening tool in 1999 (Morgan et al, 1999). It is a simple tool to indicate a possible eating disorder, which the practitioner can start with. A score of two or more positive answers is considered to be a positive screen.
The SCOFF questions include:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than one stone in a 3-month period?
- Do you believe yourself to be fat when others say that you are too thin?
- Would you say that food dominates your life?
For every yes, one point is given. A score of two or more is a likely case of anorexia nervosa or bulimia.
Signs to look out for also include physical or mental fatigue, callouses on the hands or knuckles for example ‘Russell's sign’, a distracted mental state or low mood, dizziness, poor skin condition, baggy clothing (many eating disorders cause the person to perceive themselves as ‘fat’ and to require covering up in baggy clothing, although not always – it is something to be aware of), and an avoidance of discussing the subject of weight or food.
Bulimia involves purging but this is not always through vomiting, it may be through use of laxatives or over exercising, or fasting after the binge. It is therefore worthwhile also looking at what prescriptions the patient is getting and why.
Support from healthcare professionals
We can support patients by helping them make simple changes, after we have referred them with their consent to the GP or directly to the eating disorder service if this is possible.
The pandemic has increased anxiety around food, Beat (2022) report, partly due to fear of contagion by pathogens (Monteleone et al, 2021). It is good to arrange an appointment with the appropriate person at the surgery to help the patient devise a plan of what foods the person feels comfortable with, to explore substitutes for foods they might not be able to get hold of due to the current delivery issues in the UK, and to formulate a schedule for what the person does throughout their day, so it can be easier for them to know what to do and why it is important, rather than slipping back into the old habit of food restriction. This can also all be done over a video call.
A key thing to remember is that a person with bulimia will struggle with feelings of wanting to purge after each meal and they should be helped to prepare for this. The key here is to help the person develop distraction techniques. They can develop a new habit of distracting themselves with a walk, a chat to a friend, playing a game, or watching a film, for example. The binge and ultimately the feelings of wanting to purge are less likely to happen where the person is not hungry. A small snack between meals can also be encouraged to ensure hunger does not take over, and these can be removed in time as their body adjusts to the new routine and amounts it is being fed at any one time.
Emotional support is also required, not only because it is exhausting having an eating disorder, thus triggering a higher rate of depression – also common due to the level of insecurity the person has about themselves – but also because every day emotions can trigger binges. Teach the person the BLAST method – where they are encouraged to understand if they are bored, lonely, angry, stressed or tired – as these are all triggers for bingeing and if understood at the time, the binge can be actively avoided. Mindfulness when eating should also be encouraged so the person does not lose themselves in the moment to bingeing, where it is known that dissociation can happen. By being present, better choices can be made. Don't try to force anything on the person – let them do what works for them. If they do not want to engage at all, be understanding that at this moment they may not feel ready.
The person may have coexisting untreated mental health issues, so it is important, with consent, to make the necessary referrals for therapies services or more acute help.
Effect of the pandemic
Monteleone et al (2021) found putative risk factors associated with eating and general psychopathology impairment experienced by people with eating disorders during the lockdown resulting from the COVID-19 pandemic. They found that patients perceived a low quality therapeutic relationship, fear of contagion and increased isolation – all positively associated with eating and general psychopathology worsening during COVID-19-induced confinement, as well as a reduction in satisfaction with family and friends' relationships and reduced perceived social support.
Crucially, Monteleone et al (2021) found that rather than the type of therapy or counselling given, it was the therapeutic relationship that made a significant difference to the patient. Where this was better, psychopathology severity was lower. A recent conference reported that there have been record numbers of eating disorders throughout the world in this pandemic (Feinmann et al, 2021). Some figures are still to be published. Jennifer Couturier of McMaster Children's Hospital in Ontario, Canada, explained that ‘the bombardment of social media posts and messages about “inevitable” weight gain related to staying at home.’
Interestingly, the conference also heard research that reported health professionals to be vulnerable to maladaptive eating behaviours, as explained by Mohsen Khosravi, from the University of Medical Sciences, Zahedan, Iran. ‘We know that negative emotions including anxiety, stress, depression, and anger trigger disordered eating behaviours. For healthcare professionals, the lack of medical equipment in the current crisis is accompanied by the intensification of negative emotions, triggering disordered eating’ (Feinmann et al, 2021). The conference heard that online consultations have proved helpful, however, with fewer people feeling they had deteriorated as time went on through the pandemic. Lead researcher Christine Peat, the assistant professor of psychiatry at the University of North Carolina, explained ‘Presumably, in that time, practitioners and patients have become more familiar with the technology.’ Stephen Touyz, professor of clinical psychology at the University of Sydney, told the conference that new treatments should incorporate the ‘wonderfully innovative technologies that are currently transforming healthcare’ (Feinmann et al, 2021).
‘The virtual reality sector has made spectacular advances and could now assist with body shape over-evaluation. There are smartwatches that already allow live electrocardiogram data to be recorded, and these could be developed to enable live streaming feedback at meal times, which is one of the greatest challenges for patients with eating disorders,’ Stephen Touyz stated.