When does weight loss become a problem?

March includes International Eating Disorders Awareness Week, so we spoke to Dr Eileen Feeney, Specialist Eating Disorder Consultant Psychiatrist at Priory Hospital Woking. She discusses the importance of early intervention, the most effective treatment options and how best to approach a patient you are concerned about.

Eating disorders are complex mental health conditions which can have serious life threatening consequences. They are not a fad or lifestyle choice and can have devastating effects on a person’s emotional and physical health. The earlier an individual seeks the correct eating disorder treatment, the more likely they are to make a recovery. Research suggests that around 46% of anorexia patients and 45% of bulimia patients fully recover from the condition if treated.

There are four main types of eating disorder:

• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder (BED)
• Other specified feeding or eating disorder (OSFED)

Other types of eating disorders mentioned in DSM-V (standard classification of mental health disorders), which are less common include pica, rumination disorder and avoidant/restrictive food intake disorder (ARFID).

Who can suffer from an eating disorder?

Although many eating disorders develop during adolescence, it is not unusual for people to develop eating disorders earlier or later in life. In fact, we are aware of cases of anorexia in children as young as six and some research reports cases developing in women in their 70s. Outside of the typical age bracket, people are less likely to be appropriately diagnosed due to a lack of understanding and awareness.

Recent research from the NHS Information Centre showed that up to 6.4% of the total population of adults in the UK displayed signs of an eating disorder (Adult Psychiatric Morbidity Survey, 2007). This suggests that up to 25% of those showing signs of an eating disorder were male.

Spotting the signs and symptoms of an eating disorder

GPs are often the first port of call for a sufferer but the stigma still associated with the condition can make it difficult for a patient to be forthcoming about their worries. An individual may also still believe that there could be another explanation for their weight loss.

Appearances can also be deceptive; those suffering from bulimia may be within the normal weight range or may be overweight for example. Therefore, being able to spot the signs and symptoms early is important.

Anorexia nervosa:

• Abnormally slow heart rate and low blood pressure, which means that the heart muscle is changing. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower
• Reduction of bone density (osteoporosis), which results in dry, brittle bones
• Muscle loss and weakness
• Severe dehydration, which can result in kidney failure
• Fainting, fatigue, and overall weakness
• Dry hair and skin; hair loss is also common
• Growth of a downy layer of hair - called lanugo - all over the body, including the face, in an effort to keep the body warm

Bulimia nervosa

• Potential for gastric rupture during periods of bingeing
• Inflammation and possible rupture of the oesophagus from frequent vomiting
• Tooth decay and staining from stomach acids released during frequent vomiting
• Chronic irregular bowel movements and constipation as a result of laxative abuse
• Peptic ulcers and pancreatitis

Binge eating disorder

• High blood pressure
• High cholesterol levels
• Heart disease as a result of elevated triglyceride levels
• Type II diabetes mellitus
• Gallbladder disease

Support a patient seeking help

It is very easy to say the wrong thing to someone suffering from an eating disorder. Time and time again, I have been told by the patient that "the doctor said I wasn't thin enough". An innocuous comment such as "you're looking well" may indeed be translated as "you're fat".

It is important to genuinely ask how a patient is feeling. Sometimes, the sufferer will say they "feel fat" but reassure them it is the anorexia talking rather than their true self. It is also very important not to be judgemental.

Professor John Morgan at Leeds Partnership NHS Foundation Trust designed the SCOFF screening tool to indicate a possible eating disorder. A score of two or more positive answers is a positive screen.

SCOFF questionnaire:

• Do you ever 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 you are too thin?
• Would you say that Food dominates your life?

Once an eating disorder has been diagnosed, it is important that the sufferer is given appropriate support.

Treating an eating disorder

Initially, it is helpful to do baseline blood tests and an ECG as this may need to be monitored depending on the presentation.

There are various treatment options depending on the severity of the patient's presentation. Some may be appropriate for outpatient therapy.

If the weight is very low, the initial focus needs to be on:

• Weight restoration
• Psychoeducation

There are different types of treatment modalities depending on the severity of the presentation - NICE guidelines recommend CBT-E (enhanced cognitive therapy) but other therapeutic approaches have also shown merit, for example:

• Dialectical behaviour therapy - based on a set of strategies, which emphasise that change must happen if a person is to improve their life. The treatment sets specific targets and stages to reach
• Psychodynamic therapy - aims to look at the roots of the individual's emotional distress, often by exploring motives, needs and defences

Specialist intervention improves the prognosis where inpatient treatment is required. In hospitals such as those within the Priory network, a multidisciplinary team approach is used to achieve the best outcome for patients. Usually the team is led by a psychiatrist and may consist of nurses, medical officers, dietitians and different types of therapists. It is useful to have the option of inpatient treatment if urgent help is required or if outpatient treatment or day care hasn't worked.

Priory Hospital Woking currently offers an outpatient eating disorder service to both male and female patients. In addition, it is due to open a private inpatient eating disorder service for females over the age of 18.

It is also useful to recommend voluntary organisations to patients, as a support network outside of treatment. Websites they can visit include:

• www.b-eat.co.uk
• www.nationaleatingdisorders.org