Eleanor Speakman has a masters degree in applied clinical psychology and works as a clinical advice coordinator at eating disorder charity Beat. Here, she discusses the importance of providing timely support to people who show signs of an eating disorder
The past few years have seen a significant rise in the numbers of people with eating disorders across the UK. Hospital admissions have risen by 84% since 2017, with an 82% rise in young people admitted since 2021 alone, according to the Royal College of Psychiatrists (RCPsych).1 It’s estimated that an even larger number of people with eating disorders are going undiagnosed and untreated due to signs of their illness being missed.
At the same time, healthcare professionals have experienced a huge increase in pressure and workload, particularly since the pandemic. At the eating disorder charity Beat, we know nurses play a vital role in ensuring eating disorders are better recognised, understood and treated. But nurses across the field need the right support and guidance in order to help their patients get the care they deserve.
What are the challenges in spotting an eating disorder?
Some common challenges faced by nursing staff when identifying symptoms that may indicate an eating disorder stem from a lack of screening tools, training or knowledge. At Beat we found most medical students were given less than two hours’ teaching about eating disorders during their degree.2 When we asked UK nurses about specific training in eating disorders, many told us they had received little or none.3
People with an eating disorder might hide their condition, not recognise that they are ill, or be in denial that they have an eating disorder, which can make it difficult to recognise when a patient is unwell. Secrecy is often based on worry about how others will react to their disorder, including a fear of not being believed.
For instance, it’s common for people who are unwell to feel they’re not ‘sick enough’ to seek help. While eating disorders affect an estimated 1.25 million people across the UK4 of all different weights, ages, genders and backgrounds, there are still harmful misconceptions that you must have a low BMI in order to be diagnosed, or that only younger, white females have eating disorders. This can prevent people from reaching out for help, or clinicians from spotting the signs – and in some cases, it can mean a person is denied the care and treatment they need.
What is ARFID?
Avoidant/Restrictive Food Intake Disorder (ARFID) is the avoidance of certain foods and/or restricted intake in the absence of fear of weight gain/preoccupation with weight and shape. It can result in weight loss, lack of nutritional intake, and can cause stunted growth.
It is usually due to:
• Sensory based avoidance, for example sensitivities to taste, texture, smell or appearance.
• Phobia/anxiety/distress, for example fear of the consequences of eating such as choking or becoming unwell.
• Low interest in eating, including difficulties with internal hunger cues or seeing eating as a chore.
Why do eating disorders need to be recognised and treated early?
Identifying eating disorders quickly reduces costs to the NHS and the wider economy, as people are less likely to need intensive treatment if they can access timely care. Most importantly though, early intervention results in better recovery rates and treatment outcomes, and less risk of hospitalisation and relapse.
While recovery is possible at any stage of illness, research highlights5 that even a treatment delay of three months can lead to significantly less improvement in wellbeing, due to the severity of the disorder increasing and it becoming more entrenched. This is because eating disorder behaviours are often initially rewarding for the individual, but then become habitual and over time become neurocognitively engrained, causing brain changes. Despite this though, instilling hope is powerful and should be a priority. Recovery is possible for anyone.
How can nurses help?
You may be one of the first to encounter a person with an eating disorder, whether it is diagnosed or not. This makes it important to be able to spot early warning signs of emerging and subthreshold disorders, as well as recognising factors that may contribute to developing of an eating disorder. Your role may also include:
- Evaluating and monitoring eating disorder-related risks.
- Helping to prevent the progression of the illness.
- Being the first point of contact for a person with an eating disorder.
- Making a referral for specialist treatment.
- Signposting to support services.
- Supporting service transitions and shared care.
Beat, NHS England and the RCPsych recently launched free eating disorder training for nurses and healthcare staff.6 This training is designed to help nurses at every stage of the process, including managing medical risk, communicating sensitively with patients and creating care plan pathways.
If an eating disorder is suspected, a history and physical examination of the person should be undertaken, including establishing capacity and consent. Taking a history involves investigating mental and physical health concerns as well as eating concerns. One way to determine the presence of eating concerns is by using screening tools, such as the SCOFF tool or the Binge Eating Disorder Screener-7.
Mental health concerns should include investigating common comorbidities such as obsessive-compulsive disorder and substance misuse. Physical assessment should include weight, blood pressure, muscle strength, temperature, pulse, hydration, general health and appearance, and the presence of, or changes in, other physical health conditions, such as type 1 diabetes and disordered eating (T1DE). In certain situations, urgent blood tests and investigations such as ECG or a bone scan may be needed. To help healthcare professionals to assess and manage risks associated with eating disorders, in 2022 the RCPsych created Medical Emergences in Eating Disorders guidance (MEED).7
Following this process and discussion with the patient, the next step is to refer to a community-based, age-appropriate eating disorder service for further assessment or treatment as soon as possible. This must be done in accordance with the evidence-based guidelines produced by NICE or SIGN.8,9 While a patient is on the waiting list, nurses can provide psychoeducation, support and follow-up to continue managing risk, using the resources mentioned throughout this article.
Recognising early-warning signs
The warning signs of eating disorders are not always obvious, and the person can appear physically healthy. NICE guidelines recommend being alert to the following potential signs:
• Unusually low or high BMI or body weight for their age.
• Dieting or restrictive eating behaviours that are worrying the person, their carers or professionals.
• Social isolation or withdrawal.
• Disproportionate concerns about weight and shape.
• Problems managing an illness that affects diet, such as diabetes or coeliac disease.
• Menstrual or endocrine disturbances, or unexplained gastrointestinal symptoms.
• Unexplained electrolyte imbalance or hypoglycaemia.
• Signs of malnutrition, such as poor circulation, dizziness, palpitations, fainting.
• Activities carrying a high risk of eating disorders, such as professional sport, fashion, dance, modelling or acting.
You may also identify that the person:
• Has rituals around food.
• Has low confidence and self-esteem.
• Has anxiety/distress.
• Avoids activities involving food or eating with others.
• Avoids or compulsively checks mirrors and scales.
• Has difficulties with concentration and/or sleep.
• Eats food in secret or at irregular times.
• Engages in self-harm behaviour.
We’d urge all healthcare professionals to keep in mind that while rapid weight loss in a patient should raise concern, weight is not the only factor to consider. Anyone of any weight can have an eating disorder.
What causes an eating disorder?
The harmful stereotypes relating to eating disorders include the perception that they are just difficulties with eating, a form of attention seeking, or something that only impacts young women and girls. On the contrary, eating disorders are serious mental illnesses that signal emotional distress. They can affect anyone of any age, gender, background, ethnicity and weight. They do not discriminate, and they are not a choice.
Their development is likely to involve a combination of genetic, biological, psychological, social and environmental factors. Difficulties with self-esteem, perfectionism and loneliness can contribute to an eating disorder, as can stressful life events like transitions, rapid change, illness, loss, conflict and trauma.
The more of these factors that a person experiences, the greater their risk of developing an eating disorder. Often, eating disorder behaviours act as a maladaptive mechanism to cope with difficult situations or feelings, or to feel more in control, although the person may not be aware of the purpose behind their behaviour.
It can feel incredibly difficult to support someone with a possible eating disorder for the first time. Understandably, it can be a sensitive topic for the patient, and it’s normal to worry about saying the wrong thing, giving unhelpful advice or inadvertently triggering negative emotions.
It will require all the skills you use as a nurse to build a therapeutic alliance: compassion, trust, respect, active listening, validation, mutual engagement and shared decision-making. Be aware there may be anxieties, ambivalence towards recovery and resistance to change.
Ask open-ended questions, listen without judgement and make the person feel heard and supported. There may also be considerations around comorbid mental health difficulties, age, cognitive impairment because of starvation, or additional communication needs. You may not get it right all the time, but remember we are all human and mistakes are an opportunity to talk and learn.
DNAs and follow-up
Talking about eating disorders can save lives, and we regularly hear from people who really valued the support from their healthcare team and who have gone on to live long, healthy lives away from their eating disorder.
Early identification is key. We would urge you to follow up on any concerning behaviour.
Ensuring that a robust protocol is in place for non-attendance of agreed follow-up appointments should help safeguard against undetected deterioration, or prevent those at high risk of ‘slipping through the net’. If an appointment is missed, the person coordinating the person’s care should be told, as well as the wider care team, and new appointment made. It may be helpful to ask if the person needs support to enable them to attend, such as writing a letter for their employer.
Always reach out to eating disorder experts for guidance and support if you need it.
- Royal College of Psychiatrists. Hospital admissions for eating disorders increased by 84% in the last five years. 2022. Link
- Beat. How many people have an eating disorder in the UK? 2022. Link
- Beat. Training for nurses. 2017. Link
- Beat. Worth more than 2 hours. 2022. Link
- Beat. Delaying for years, denied for months. 2017. Link
- NHS England. Eating disorder training for health and care staff. Link
- Royal College of Psychiatrists. Medical emergencies in eating disorders (MEED). 2022. Link
- NICE. Eating disorders: recognition and treatment. 2020. Link
- SIGN. Eating disorders. 2022. Link