ED Awareness Week - joining the campaign for all UK medical schools to offer clear and comprehensive training on Eating Disorders

It’s Eating Disorders Awareness Week, and we are incredibly pleased to see that BEAT is using this week to campaign for all UK medical schools to offer clear and comprehensive training on eating disorders. This is incredibly important. GPs are on the front line, often the people who spot early warning signs of eating disorders, or who are the first port of call for people who are struggling. Not only that, but GPs are being relied upon more and more to support people who are on long waiting lists for specialist treatment, or to support those who don’t meet increasingly high thresholds for specialist secondary care. 

There are so many myths around eating disorders - for example that people can only have eating disorders if they are at a certain weight or are engaging in certain behaviours (such as vomiting). Why should we expect doctors to think differently to members of the general population if they are not given specialist training? This is made all the more complicated by frequent changes to eating disorder diagnoses. The diagnostic manual DSM V was released in 2013, increasing the number of eating disorder diagnoses from three to eight and changing the diagnostic criteria for the original diagnoses, with further revisions due in the DSM-V-TR in March. 

It is our belief, that all medical doctors, not just GPs, would benefit from ED training.  Eating disorders are often hidden disorders, meaning they can present in all sorts of ways. Someone might see a doctor because they can't sleep (because their body is on high alert for food) or because they are having gastrointestinal issues (because they are eating too little, or because their gut is unable to process food normally because of vomiting or laxative use) or because they are obese (but are actually struggling with binge eating disorder). It would be incredibly helpful if all doctors had comprehensive training in eating disorders, allowing them to consider whether an eating disorder might be relevant for the patients they are seeing. 

What might be helpful for GPs?

GPs have an increasingly complex role to play, in both identifying and supporting people with eating disorders. Not only that, but work loads are increasing, and appointments are frequently remote, meaning doctors are having to work out what is going on without laying eyes on their patients. I spoke to some local GPs to ask them what support they might welcome: 

• myth busting

• knowing how to recognise patients with eating disorders, particularly in a remote appointment

• knowing how to support patients who are waiting for specialist treatment

• knowing where to signpost patients who have disordered eating or eating disorders but who don't meet the thresholds for specialist care

• knowing how to best help the families of patients with eating disorders

• knowing how best to support patients who are physically ill with their eating disorders (e.g. electrolyte imbalances or risk of refeeding syndrome) and how MDT working could support this 

• having a list of do's and don'ts to give doctors more confidence to discuss concerns with patients without fearing causing distress

• giving doctors a better understanding of the psychological components of eating disorders

A helping hand

 Whilst nothing can replace comprehensive training, here are some top tips to help identify when an eating disorder might be part of the problem and to consider how to manage that:

• Eating disorders can affect people at any weight or size. Whilst low weight might be indicative of an eating disorder, weight and BMI are a very imprecise tool. It is much more helpful to explore people's weight history and changes in weight, and their thoughts and feelings about shape and weight.

• If someone is reporting as being low weight, ask about how they feel about weight gain and how they are trying to achieve it, their ideal weight, and their view of their body image. Someone who has lost a significant amount of weight or who constantly yoyo's might be more at risk of an eating disorder, even if their BMI still appears "normal". 

• It's worth asking what is eaten on a typical day, as people with eating disorders can have a distorted view about what is "normal" daily intake. 

• If you suspect an eating disorder, remember that compensatory behaviours can be varied. Whilst people often ask about vomiting or taking laxatives, you could also ask about exercising to control shape/weight, taking slimming pills or recreational drugs to control shape and weight, or skipping meals/restricting. Consider insulin misuse in diabetes.

• Look out for the consequences of restrictive or irregular eating: fatigue, constipation, reflux, hair loss, or amenorrhoea

• Are there other comorbid mental health problems? Mood disorders and social withdrawal are frequently (although not always) seen in those with eating disorders. Ask about self harm and suicide - 20% of deaths in those with anorexia are due to suicide.

• Ask about any family history of eating disorders and about family attitudes to eating, shape and weight, particularly for those still living in the family home

• Try to be curious and non-judgmental. People with eating disorders often feel huge amounts of shame about their weight or bingeing. If you can ask about this in a compassionate way, you are more likely to get an honest answer.

• Try not to label things as "good" or "bad". Seeing "healthy" meals and exercise as "good" can lead to you missing eating disorders, and talking about "bad" or "junk" food, "lazy" behaviour or "fatness" can cause shame and lead people to avoid seeking help

• Consider using an eating disorder assessment tool (such as the one available on the NICE website - https://www.nice.org.uk/guidance/ng69/resources) or a screener such as the SCOFF questionnaire (but don't rely on the SCOFF alone). 

• Consider physical health checks:

  • weight (BMI for adults, centile charts for children). Be aware of the risks of people falsifying their weight. 

  • temperature (hypothermia is a red flag)

  • pulse rate (bradycardia or postural tachycardia are red flags)

  • blood pressure (hypotension or a drop in blood pressure on standing are red flags)

  • hydrations state

  • peripheral circulation

• Use helpful protocols from the Royal College of Psychiatrists to consider clinical features and the risk they indicate. You can find many of these protocols on the information section of our website

  • Kings College Guide to Medical Risk Assessment in Eating Disorders

  • Marsipan: Management of really sick patients with anorexia nervosa 

  • Junior MARSIPAN: Management of really sick patients under 18 with anorexia nervosa 

We hope that these tips are helpful, but nothing will replace thorough, specialist training. If you would like to support BEAT in their endeavour to encourage proper training for all UK medical schools and foundation programmes, take a look at their website to see how you can be involved. 

Here at The London Centre we know how specialist and complex eating disorders are.  If you are a doctor or GP wanting further support or training in managing eating disorders, do feel free to contact us on info@thelondoncentre.co.uk and we will be more than happy to help.

If you wish to book an appointment, please click here.