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Practical strategies for people with eating disorders

Maggie Young
Team Coordinator Sheffield Eating Disorders Service Sheffield Care Trust
E:Eating.DisorderService@sct.nhs.uk

Amy Wicksteed
Clinical Psychologist Sheffield Eating Disorders Service
Sheffield Care Trust

Lorraine Tilsley
Practice Nurse Porter Brook Medical Centre

Helen Root
Practice Nurse University of Sheffield Health Service

The NICE eating disorders guideline issued in January 2004 summarises good practice regarding the treatment and management of four types of eating disorder:(1)

  • Anorexia nervosa (AN) is characterised by ­significant weight loss and an intense fear of weight gain or becoming fat.
  • Bulimia nervosa (BN) is characterised by binge eating and purging, although weight usually remains in the normal range.
  • Binge eating disorder (BED) is characterised by binge eating in the absence of purging, which ­usually leads to significant weight gain.
  • Eating disorder not otherwise specified (EDNOS) is when the sufferer fulfils some, but not all, of the criteria for the other eating disorders. This is becoming more prevalent, particularly in the younger age group, among whom it is estimated that 6-9% of teenage girls may have an atypical eating disorder.(2)

There is now an increasing emphasis on what eating disorders have in common, rather than the differences between them. Most people with eating disorders have low self-esteem and a tendency to overemphasise body shape and weight as a measure of self-esteem. In AN, body image may be distorted, with the sufferer believing she is fat when she is actually severely underweight.

Implications for primary care
The NICE guideline has important implications for primary care. It recommends that, for patients seeking help in primary care, the GP should take lead responsibility for the initial assessment and coordination of care. As eating disorder services are patchy throughout the UK, it is likely that many patients with mild to moderate eating disorders will be managed in primary care. In Sheffield, the award-winning "Eating disorders in primary care project" embodies many of the principles of the NICE guidelines. The project promotes early intervention and the provision of high- quality information and support to patients and their carers. The project also empowers nonspecialist staff to deliver evidence-based interventions for patients with less complex problems. Nurse-led "eating disorders outreach clinics" have been established in two practices that predominantly serve the student population. Based on this experience, practice nurses have developed their role in the assessment and treatment of mild to moderate eating disorders using a guided self-help model (see Table 1). The following article summarises the Sheffield experience and shows how, with appropriate training and supervision, the practice nurse role can be developed.

[[NIP17_table1_60]]

Practice nurses are ideally placed to manage patients with eating disorders due to a range of transferable skills that most will already be familiar with:

  • Giving dietary advice.
  • Basic counselling skills.
  • Likely physical complications of eating disorders.
  • Motivational programmes (eg, smoking cessation).

Practice nurses are also well positioned to screen for potential cases, both during routine consultations and at the new patient health check.

Identification and screening
Although eating disorders affect males and females, target groups for screening are young women with low body mass index (BMI) and women with gynaecological, gastrointestinal or psychological difficulties. Research has shown that, during the years leading up to a diagnosis being made, individuals with eating disorders have often consulted their GP with the above problems while not disclosing their eating disorder.(3)
A diagnosis of an eating disorder is rarely made on the basis of a physical examination. However, possible indicators of AN may include:

  • Rapid weight loss or a BMI >18.
  • An intense fear of weight gain.
  • Poor circulation.
  • Amenorrhoea and lanugo hair (fine, downy hair that is sometimes present in severe starvation).

BN is often more difficult to detect as it is usually shrouded in shame. Possible indicators may include:

  • A hoarse voice.
  • Swollen parotid glands due to frequent vomiting.
  • In severe cases, Russell's sign (skin damage on the hand where someone has frequently used their fingers to induce vomiting) may be observed.

Due to the shame associated with eating disorders, patients often have difficulty in making a disclosure. NICE recommends asking direct questions such as: "Do you think you have an eating problem?" or "Do you worry excessively about your weight?" Should these questions lead to a disclosure, the SCOFF questionnaire may be used. This consists of five questions, which may be asked in any order:

  • 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 three-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?

Score one point for every "yes" answer; a score of 2 or more indicates that the patient is likely to have an eating disorder.(4) These cases should always be followed up by an assessment.

Assessment
Initial assessment should be with either the GP or a practice nurse liaising closely with the GP. An initial assessment will usually require at least a 20-minute appointment. The assessment process may take place over two or three appointments. At assessment it is always important to bear in mind that this may be the first time that the patient has ever discussed their problem. Assessment should include questions to elicit:

  • A brief history of the eating ­difficulty and any obvious ­precipitating factors.
  • Current eating patterns, including frequency of any binge eating and purging.
  • Attitude to body shape and weight.
  • The patient's mood and any evidence of self-harm or substance misuse.

Physical assessment should include measurement of height and weight to calculate BMI. Blood tests should be carried out, usually FBC, U&Es, LFT and TFT, to identify any physical complications (eg, low potassium) and to exclude other causes of weight loss. The aim of the assessment is to assess severity of the eating disorder, to identify and manage any risk factors and to develop a constructive management plan. High risk factors are: severe emaciation, significant weight loss (specifically BMI The mild and moderate cases described in the following vignettes would be more suitable for practice nurse involvement and intervention.

Mild
Sally is a 28-year-old PE teacher who has had a mild eating disorder since her early twenties. Her BMI is 18.5 and she follows a strict calorie-controlled diet to maintain her weight. When she exceeds her self-imposed calorie limit she feels guilty and induces vomiting. This occurs approximately twice a week. She has now decided that "enough is enough" and has requested help with the practice nurse.

Moderate
Diane is a 24-year-old administrator who has recently been signed off sick from work with depression after a relationship break-up. She has a history of "yo-yo" dieting, which over the past 6 months has escalated into daily episodes of restricting of what she eats followed by binge eating and self-induced vomiting. Her eating difficulties are accompanied by episodes of binge drinking; both of these have resulted in her accumulating debts. She feels out of control and has decided to seek help.
Should patients deteriorate, practice nurses should consult their GP regarding the need for a referral to secondary care.

Treatment options in primary care
NICE builds on the guidance regarding eating disorders in the NSF for mental health.(5) This states that most mild eating disorders can be managed in primary care and that dietary education, monitoring of food intake and the provision of accessible, structured information are important components of treatment. NICE emphasises the importance of providing patients and carers with education and information about eating disorders and the availability of local and national support groups (see Resources). This fosters a collaborative approach to care that enables patients to be well informed and active in making choices about their treatment.
NICE recommends that, as a possible first step, patients with BN and BED should be encouraged to follow an evidence-based self-help programme. Healthcare professionals should consider providing direct encouragement and support to patients undertaking the programme as this may improve outcomes.  This may be sufficient treatment for some mild cases.
Evidence-based self-help manuals have been developed based on cognitive behaviour therapy (CBT) for BN and BED, and more recently manuals have also been developed for use with patients with AN (see Resources). The manuals are designed for use either on a purely self-help basis or with support from a guide who may or may not be a professional.
Practice nurses involved in the Sheffield project have developed skills that enable them to support patients through a guided self-help programme, while also monitoring their physical and mental health. The programme follows a step-by-step approach to change and can be delivered over 6-8 half-hour appointments. Before embarking on supporting a patient using guided self-help, it is essential that the nurse becomes familiar with the steps presented within the self-help manuals.
Often, the first step is to provide the patient with some information regarding their eating disorder. Increasing the patient's knowledge of the physical complications of their eating disorder, such as the impact of restricting food intake on the metabolism or the impact of frequent vomiting on dental enamel, is an important starting point. This can be useful in helping build the patient's motivation to change. It is important to acknowledge that patients are often ambivalent and fearful to let go of what has become a reliable coping mechanism.
The next step is to begin monitoring food intake using a "food and feelings" diary. The purpose of this is to increase the patient's awareness of their current eating patterns and to identify triggers for eating behaviours. These may include long periods of time without eating or sources of anxiety that may lead to food avoidance or binge eating. When the current eating pattern has been established, the next step is to work towards a regular eating pattern through meal planning. The next stage is to support the patient to develop a range of coping strategies to deal with these trigger situations.
The final steps involve looking at issues that may have been maintaining the behaviour, such as low self-esteem, poor body image and a reluctance to eliminate dieting. Relapse prevention is also covered. All the manuals cover these areas, providing suggestions and CBT-based exercises to address these difficulties.

Conclusion
Practice nurses can provide guided self-help treatment for eating disorders in weekly sessions, combining monitoring of physical and mental health with psycho-education, nutritional advice and emotional support. The recent NICE guideline and the experience of the "Eating Disorders in Primary Care Project" provides a model for extending the practice nurse role in managing these disorders. Both patients and staff can benefit from extending the practice nurse role, as this provides an opportunity to provide early intervention to patients who may not meet criteria for referral to specialist services but do have significant distress as result of their difficulties. In Sheffield, the primary care eating disorders outreach clinics are easily accessible, and patient-friendly and deliver an evidence-based package of care. We believe that these clinics provide a useful model for wider service development.

Acknowledgements
The Eating Disorders in Primary Care Project is a collaboration between Sheffield Eating Disorders Service, University of Sheffield Heath Service, Porter Brook Medical Centre and South Yorkshire Eating Disorders Association. The authors wish to acknowledge financial support from: Sheffield Health Action Zone, Sheffield West PCT and Sheffield Care Trust.

References

  1. NICE. Eating disorders - clinical guideline 9. London: NICE; 2004.
  2. Eating Disorders Association. A guide to purchasing and providing services. Norwich: EDA; 1995.
  3. Ogg EC, et al.  General practice consultation patterns preceding diagnosis of eating disorders. Int J Eat Disord 1997;22:89-93.
  4. Morgan J, et al.  The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467-8.
  5.  Department of Health. NSF for mental health. London: DH; 2000.

Resources
The eating disorders unit at the Maudsley
W:www.web1.iop.kcl.ac.uk/iop/Departments/PsychMed/EDU/index.shtml  Eating Disorders project
W:www.edglos.org.uk
Eating Disorder Association
W:www.edauk.com/
NICE
W:www.nice.org

Further reading
Sheffield Eating Disorders Service. The personal notebook: a self-help guide. A patient workbook to accompany the self-help programme. Please contact: Shona.McBride@sct.nhs.uk
Crisp AH. Anorexia nervosa and the wish to change. 2nd ed. Hove: Psychology Press; 1996.
Treasure J. Anorexia nervosa: a survival guide for families, friends, sufferers. Hove: Psychology Press; 1997.
Freeman C. Overcoming anorexia nervosa: a self-help guide. London: Robinson Press; 2002.
Cooper P. Bulimia nervosa and  binge eating - a guide to recovery. London: Constable & Robinson; 1993
Schmidt U, Treasure J. Getting better bit(e) by bit(e). Hove: Psychology Press; 1993.
Fairburn CG. Overcoming binge eating. New York: Guildford Press; 1995.