This paper aims to consider the role of informal social support in contributing to the welfare of people with eating disorders (EDs). Anorexia nervosa usually emerges between the ages of 16 and 17 years for females and at 12 years for males, followed by other common forms of EDs, such as bulimia nervosa and binge eating disorder. Families can play a key role in the outcome of an ED by recognising the problem and accessing early support. Unfortunately, the provision of services does not match the current need. Carers have been involved in co-designing and co-delivering information and support that can fill some service gaps. This involves learning how to manage the traps that are easily triggered and lead to unhelpful interactions driven by expressed emotion, such as overprotection, accommodating the ED behaviours by ignoring and/or using hostile confrontation and criticism. Families provide a great amount of practical support and are important partners during treatment. They can prevent the individual from becoming isolated and trapped within the ED identity.
Consultant eating disorder (ED) psychiatrists play a lead role among the multidisciplinary team within ED services, as their skill set equips them to manage these complex disorders effectively using a multidimensional approach. The aim of this audit was to determine the degree of alignment of consultant ED psychiatrist roles with the 2014 Royal College of Psychiatrists guidelines (1), focusing on clinical work, leadership and educational responsibilities. Fifteen consultant ED psychiatrists were interviewed and their self-reported roles were compared to the guideline set by the Royal College. The data showed that clinical responsibilities were the most consistently performed (100%), while educational roles, specifically external education, were least represented (13.3%). Leadership responsibilities, mainly service development, were also prominent (80.0%) but some psychiatrists reported insufficient time for other responsibilities, such as therapeutic work and training. No psychiatrist was able to fulfil all of the roles described in the 2014 guidelines. This audit highlights the differences between Royal College expectations and current practice, emphasising the importance of further investment in consultant ED psychiatry to enhance service delivery.
Introduction: The field of eating disorders (EDs) has evolved dramatically in recent years, with an increasing focus on community treatment because of better acceptability, both to children and young people (CYP) and parents/carers. Furthermore, this may provide a more cost-effective approach than inpatient care. Aim: This study aimed to explore the perspectives of service leads operating intensive outpatient programs (IOPs) for CYP with EDs. To achieve this, we convened advisory groups composed of current service leads and conducted focus group sessions. Methods: Advisory groups of service leads in established IOPs across England participated in focus group sessions to discuss initial successes and challenges in setting up IOPs for CYP with EDs. Four virtual focus groups were conducted via Microsoft Teams between December 2022 and January 2023. Sessions were recorded, transcribed and analysed using inductive thematic analysis to identify key themes. Results: Four main themes were identified for the successful running of IOPs, (1) approach, (2) team considerations, (3) patient considerations and (4) commissioning. A key sub-theme emphasised the importance of flexible and creative approaches in IOPs to supplement existing evidence-based therapies. Conclusion: IOPs for EDs appear to enable improved community treatment tailored to individual patient needs. They are flexible, equally effective and less disruptive to the young person's development than inpatient care.
Eating disorders (EDs) are severe psychiatric disorders that affect women in reproductive age. Although ED features tend to reduce during pregnancy, remission may only be temporary, with features typically resurfacing during the postpartum period. There is evidence that women with EDs may have increased risk of adverse pregnancy and birth outcomes and be more vulnerable to psychiatric comorbidities such as depression and anxiety. Maternal EDs may also have implications for child psychological, cognitive and eating behaviours. Pregnancy and motherhood, particularly in the early stages, is an opportune time in a woman's life for health professionals to engage with affected women and initiate appropriate treatment and support to promote the best possible maternal and infant outcomes.
Background: A number of studies have been published in recent years examining disordered eating behaviours (DEBs) in children and young people (CYP). Objective: To provide an up-to-date review of prevalence rates across a range of DEBs, including food addiction, in CYP living with overweight and obesity, across both community and clinical populations. Methods: In January 2022 three separate databases were searched (PubMed, MEDLINE and PsycINFO) for papers published after April 2016. The search was updated in February 2024 using identical search terms across (MEDLINE, Embase and OVID Journals). Data were extracted by the main author, and prevalence rates of DEBs calculated from available data, if not already provided. Included studies were categorised as examining: binge or loss of control eating (LOC) only, food addiction and a range of DEBs. Results: 44 studies were included in this review. Of these 37 were cross sectional, three were cohort studies, two were prospective observational studies and 2 were case-control studies. The total number of participants across all included studies was 28,640. In studies focusing on binge or LOC eating alone, prevalence rates and methods of data collection varied widely. Amongst clinical samples, rates of binge eating pre-bariatric surgery were 37.7% dropping to 18.5% at 5 year post surgery. For young people living with obesity and concurrent Attention Deficit Hyperactivity Disorder (ADHD) and/or ASD, 65% reported binge eating symptoms. In community samples rates of binge/LOC eating ranged from 8.8% to 52.8%. Within studies looking at food addiction in clinical populations, rates ranged from 9.9% to 30.8%. In community samples this ranged from 16.2% to 23.8%. The Yale Food Addiction Scale (YFAS) and YFAS-Child version were used across all studies collecting data on food addiction, meaning greater consistency and generalisability of results when compared to studies assessing binge/loss of control (LOC) eating or a range of DEBs. Amongst studies assessing a range of DEBs, one study found that there was presence of at least one disordered eating behaviour in 82.2% of a clinical population of adolescents living with obesity. Studies looking at a range of DEBs in community samples found prevalence rates ranging from 8.4% to 59.8% using a range of assessment tools. Discussion: Heterogeneity between studies in terms of assessment tools used, methods of data collection and types of DEBs assessed limits conclusions about the true prevalence of disordered eating among CYP, and how many might reach a diagnostic threshold for an eating disorder diagnosis. Further research is needed to help inform service delivery and effective referral and treatment pathways.
The National Institute for Health and Care Excellence (NICE) guidelines are evidence-based recommendations intended to inform clinical decisions on the prevention and management of specific health conditions in the national health services of England and Wales. Recommendations made in the guidelines are based on evidence from systematic reviews of the published literature and expert opinion and are developed by the National Guideline Alliance. The NICE guideline for the recognition and treatment of eating disorders (NG69) was published in 2017, replacing the previous 2004 guideline (CG9) and reflects a substantial increase in the evidence base in the intervening period. The guideline covers assessment, diagnosis, treatment, monitoring and inpatient care for children, young people and adults with eating disorders, specifically anorexia nervosa, binge eating disorder, bulimia nervosa and other specified feeding and eating disorder. Avoidant/restrictive food intake disorder, pica and rumination disorder are not covered. The guideline emphasises the importance of early intervention and treatment by specialist, community-based eating disorder services and the involvement of family and carers in supporting recovery. Psychological treatments, which might be eating disorder–focused cognitive behavioural therapy, eating disorder–focused family therapy or guided self-help, depending on the specific diagnosis, are recommended as the primary intervention for all eating disorders covered by the guideline. Medication is not recommended as the sole treatment for eating disorders but can be used as an adjunct. The guideline suggests collaboration with other specialist healthcare services to manage physical and mental health comorbidities, for example diabetes, and to manage the treatment of eating disorders in individuals who may be at particular risk of adverse outcomes, for example pregnant women, children and young people. Inpatient or day-patient care is recommended for those with severely compromised physical health. The guideline also provides guidance on the delivery of compulsory treatment under the Mental Health Act for individuals whose physical health is at serious risk.
Be Body Positive (BBP) is a psychoeducational website offering information and prevention strategies to children and young people (CYP), parents/carers and professionals across three modules: (1) body image and healthy eating, (2) selective eating versus avoidant/restrictive food intake disorder and (3) disordered eating versus eating disorders. The platform allows for easy access to evidence-based prevention/early intervention strategies created by clinicians with feedback from CYP and parents/carers. It is the product of a partnership between East London NHS Foundation Trust, North East London NHS Foundation Trust, Barnardo's and the East London Business Alliance, with funding by the NHS Transformation Directorate. Since its launch in May 2023, BBP has reached an audience of over 21,000 users, of which 18,000 are in the UK (as of 23 September 2024). Over 90% (n = 411) of professionals attending two national webinars indicated they are likely to use BBP to support CYP.
Had a paper on gender differences in eating disorders (EDs) been written in the 1970s, it would likely have included discussion of whether males should be eligible for the diagnosis of the sole eating disorder that was recognised at that time, namely, anorexia nervosa. There might also have been discussion of the clinical characteristics of male patients and whether and how these differed from those of female patients. Otherwise, the focus would have been on the factors that led some young women to develop the "morbid preoccupation with weight loss" that was considered the defining characteristic of the condition. Since this time, the issue of gender differences in EDs has become increasingly complex as the number and diversity of conditions deemed to constitute an ED has proliferated and the proportion of these conditions accounted for by males has increased. In the current contribution, it is proposed that gender differences in EDs should be viewed in the context of an ongoing process of medicalisation, whereby problems that were previously deemed to be societal in nature or, indeed, not problems at all, have come to be seen as disorders demanding clinical and public health attention. It is suggested that medicalisation should be viewed as a key variable accounting for change in the gender distribution of EDs over time and that the occurrence, drivers and ramifications of this process warrant greater attention in future discussions of this issue.
Eating disorders (EDs) have a lifetime prevalence of 8.4% for women and 2.2% for men. Anorexia nervosa (AN) and bulimia nervosa (BN) are commonly encountered in medical practice. The main medical issue for BN and the binge-purge subtype of AN is electrolyte disturbance associated with purging and vomiting, which untreated can be fatal. This loss of K+ and Cl− with associated hypovolaemia may lead to hypokalaemic alkalosis. Treatment is by fluid and electrolyte replacement. Damage to the upper gastrointestinal (GI) tract, including reflux oesophagitis, dental problems, aspiration and, occasionally, oesophageal rupture, can occur. In patients with the restrictive form of AN, the biggest risks are weight loss and malnutrition, which can have profound effects on the heart, gut, endocrine system and bone. Safe refeeding is essential. The risk to the person should be assessed using comprehensive, graded, multifactorial assessment tools, for example, Medical Emergencies in Eating Disorders (MEED). There is increasing evidence that patients can be safely refed at higher rates than was previously recommended, but it is important to assess the risk of refeeding syndrome and reduce the rate of refeeding if it is high. Underfeeding syndrome, where patients fail to establish an adequate intake, is equally important. It is critical to manage anorexic behaviour on the ward to prevent it from frustrating the process of refeeding and stabilisation. Using established protocols, communicating effectively with the patient and their family, and being aware of the methods that may be used to avoid weight gain is important, as is an understanding of mental health legislation if the least-restrictive measures fail. Recognising that the ED drives the behaviour of the patient and externalising the disorder, rather than blaming the patient, is important. Patients with EDs have high rates of functional GI disorders and bone problems. A multidisciplinary approach to treatment is essential.
Nasogastric tube (NGT) feeding is a common medical intervention used to help malnourished patients meet their nutritional needs. Occasionally this is used to help patients with restrictive eating disorders if they are unable to meet their nutritional requirements through oral diet or supplements when appropriate meal support is given. NGT feeding against a patient’s will, requiring physical interventions to maintain their safety, can be used to stabilise a patient medically in lifesaving scenarios. Recent research highlighted the extent of this practice within mental health wards in England, with 622 patients reported to have received this intervention in a one-year period. The length of time for which this intervention was required ranged from a single feed to 17 patients receiving it for over a year, and one patient for six years. These findings have raised ethical and legal concerns regarding the extent of this restrictive intervention and the associated physical, emotional and psychological risks it carries for the patient, as well as the emotional and psychological risk to the inpatient peer group, parents/carers and the staff involved. This paper aims to suggest the best ethical, legal and clinical practice regarding this intervention for those practicing in England and Wales.
Eating disorders are serious psychiatric conditions which severely compromise the ability to engage in normal day-to-day living. National guidance recommends that patients are treated not by individuals but a multidisciplinary team. In the past, dietitians have been excluded from some manualised treatments for eating disorders and this has led to poor investment within some teams. However, the dietetic role goes beyond refeeding management and meal planning. This paper highlights the multiple areas where dietitians have been embedded within specialist teams and have developed advanced practice. It also explores how dietitians can bring their expertise to all areas of eating disorder treatment, including meal support, prescribing, nasogastric feeding and therapy, including, but not limited to, all variations of eating disorder cognitive behavioural therapy, family therapies for eating disorders, guided self-help and specialist supportive clinical management.
Eating disorders have historically been considered "culture-bound" phenomena, confined to Western societies and specifically, young White females with, predominantly, anorexia nervosa. Eating disorder research tended to align with these perceptions and, until relatively recently, few studies had been conducted to establish the prevalence of eating disorders in non-Western countries. Evidence from epidemiological surveys, undertaken largely in the last three decades, have shown that eating disorders are present in African, Asian, Middle-Eastern and South American societies and in many cases the prevalence estimates are comparable to those in the West. However, there is evidence to suggest that precipitating factors, presentations and cultural perceptions of eating disorders differ between sociocultural contexts. This may result in underdiagnosis of eating disorders in non-white individuals and may be a barrier to successful management. These considerations are exemplified by studies in the South Asian population in the UK which have shown a different symptom profile than white individuals. Clinicians who are not attuned to these cultural differences, may fail to recognise an eating disorder diagnosis. South Asian populations may present with somatic concerns and the absence of "fat phobia". Culture-specific familial expectations, religious observances and issues of self-identity may have a greater role in the development and maintenance of eating pathologies in this, and other, minority ethnic groups. Greater awareness of these factors among clinicians would increase the prospects for recognition, diagnosis and successful outcomes.
Eating disorders (EDs) are complex psychiatric conditions characterised by disturbances in eating behaviours and associated psychological impairments. Despite being traditionally distinct from addiction disorders, increasing evidence highlights significant overlaps in their neurobiological and behavioural underpinnings. This article explores the potential for EDs to be conceptualised, in part, as addiction disorders. It examines mechanisms such as the activation of dopamine reward pathways, endorphin release and the anxiolytic effects of starvation-induced ketosis, which may create addictive processes within EDs. Behavioural parallels, including impulsivity, compulsivity and neurochemical alterations in bulimia nervosa (BN) and binge-eating disorder (BED), further align these disorders with substance use disorders. Additionally, food and exercise addiction, often comorbid with EDs, are evaluated in the context of their shared neural circuits and psychosocial drivers. Distinctions between EDs and addictions are also discussed, highlighting differences in aetiology, reward mechanisms, social acceptability and recovery dynamics. Understanding EDs through the lens of addiction has profound implications for treatment, including the integration of addiction-focused therapeutic strategies and pharmacological interventions targeting dopaminergic and opioid pathways. This framework offers new insights into the aetiology, psychopathology and treatment of EDs, with the potential to improve outcomes for individuals suffering from these life-threatening disorders.
Currently, one in five people with an eating disorder may develop a longstanding illness and there are delays of up to a decade in people accessing evidence-based eating disorder informed treatment. Such delays contribute to the high personal and community burden of eating disorders. The present paper reports known actions that are likely to overcome barriers to and enable early prevention in eating disorders across four themes within public health and primary care interventions. These are as follows: (1) public health programs to increase health literacy and reduce stigma, for example, Mental Health First Aid; (2) increased screening and early identification in primary care, for example, upskilling family doctors; (3) wide dissemination of accessible online and similar treatments, for example guided self-help cognitive behavioural therapy; and (4) whole of health service and similar developments to facilitate early eating disorder informed care, for example, the First Episode and Rapid Early intervention for Eating Disorders (FREED) program. Whilst there is robust evidence for many interventions, in particular guided self-help (including family therapy) and virtual forms of cognitive behavioural therapy, as well as general practitioner education, major gaps in knowledge are identified. These include the research base for healthcare first responder training in eating disorders, more recently defined disorders, particularly avoidant/restrictive food intake disorder, and the translation of effective screening instruments into regular and more widespread use. The conclusion is, however, optimistic, given the growing evidence base, widening recognition and use of effective interventions and contemporary contributions of people with lived experience.
Given the increasing prevalence of eating disorders, a greater awareness of risk factors among clinicians is essential. This should enable appropriate screening for at-risk groups, reducing the risk of developing eating disorders and prompting individualised treatment programmes. The risk factors for eating disorders are multifactorial, and we will discuss factors under the following domains: demographic, biological and developmental, personal, psychological and sociocultural. Protective factors will also be discussed.
Purging disorder (PD), a DSM-5 other specified feeding or eating disorder, involves purging in the absence of binge eating among individuals who are not underweight. Epidemiological studies indicate that PD is more common in women than men and affects 1.3% to 4.8% of girls. Clinical presentation includes elevated body image concerns, mood disturbance and perfectionism, similar to other eating disorders. However, PD is characterised by greater somatic complaints compared to other eating disorders, including greater postprandial gastrointestinal distress compared to bulimia nervosa (BN).Prospective risk factors for PD onset differ from those for anorexia nervosa onset and include higher premorbid body mass index, body dissatisfaction and dieting. Relative to its prevalence in the general population, PD is rare in eating disorder treatment settings. Treatment dropout is high in PD, with more than a third of patients discontinuing treatment early. Less than half of those with PD are free from an eating disorder at the end of treatment and at one or more years of follow-up. Recommendations for tailoring cognitive behavioural therapy include applying techniques for mood intolerance to address emotional and gastrointestinal distress that maintains purging in the absence of binge eating. Such efforts may benefit patients with PD as well as those who purge across eating disorder diagnoses.
Anorexia nervosa (AN) is primarily a mental disorder, characterised in modern society by disturbed attitudes towards weight, body shape and calorie balance. In earlier eras, anorexia did exist but religious or other values, rather than body image concerns, underlaid the obsessive-compulsive features. Serious physical and psychological complications cause high levels of disability and mortality. Early psychological intervention improves outcomes, but 20% develop severe and enduring symptoms and it has the highest mortality rate of any psychiatric disorder. AN has a biological component and shares significant genetic and neural network abnormalities with other mental illnesses, especially with obsessive-compulsive disorder (OCD). Functional neurosurgery, including stereotactic ablation (SA) and deep brain stimulation (DBS), are low-risk interventions that disrupt abnormal synchronised activity in neural circuits. Primarily used in movement disorders, these interventions are increasingly used in mental disorders, with evidence of efficacy from multiple randomised controlled trials in OCD and Gilles de la Tourette syndrome. Open-label studies of SA and DBS for AN report a large positive effect size on core psychopathology, quality of life and body mass index, sustained over many years. Early comorbid OCD symptoms and restricting AN subtype may be good prognostic predictors of response. Several surgical, psychological, logistical and financial factors may favour SA over DBS. However, the available evidence is limited and further studies are required to determine patient perception of, selection for and response to neurosurgery. AN is a potentially rewarding area for greater collaboration between eating disorders experts and functional neurosurgeons and offers hope to severely affected patients who have run out of treatment options.
Over recent decades, for young patients with anorexia nervosa (AN), efforts have been made to develop alternative treatments at home to reduce long hospital stays or to avoid admissions altogether. This article explores the motivation for developing home treatment for this specific patient group as an advance in community treatment. Two main routes of home treatment have been developed: home treatment as an "add-on" to outpatient treatment and "stepped-care" home treatment after short inpatient treatment. Both treatment approaches are discussed in this article. Pilot studies with small sample sizes have provided evidence for the safety, feasibility and success of both home-treatment approaches for AN in children and adolescents with the help of their families. Home treatment is emerging as a promising strategy for avoiding hospital admissions and reducing the duration of hospital stays. However, even though the existing research so far is promising, further validation through rigorous multi-centre, randomised, controlled trials with larger sample sizes and comprehensive follow-up assessments is warranted.
A greater susceptibility to development of eating disorders (EDs) has been recognised among people with autism since the 1980s. Standard treatment approaches for EDs can be less effective for those with autism or autistic features, but there are no separate guidelines for the management of EDs in this population. The clinical need for autism to be understood and accommodated better in ED services has become increasingly apparent in recent years. The PEACE (Pathway for Eating disorders and Autism developed from Clinical Experience) pathway, was launched by the London Maudsley Hospital in 2017 and is the first treatment approach to be developed specifically for autistic adults receiving inpatient treatment for an eating disorder. Following the success of the PEACE pathway in London, three years of innovation funding was granted to child and adolescent ED services in Buckinghamshire, Oxfordshire and Berkshire (BOB) to support the local implementation of this approach in community services. The aim was to apply similar principles while offering reasonable adjustments and ensuring the delivery of neuroinclusive care. Initial evidence suggests that the proactive, neuro-affirming approach to ED treatment in young people with autism emphasised by PEACE can improve treatment experience, reduce risk and shorten or avoid higher-intensity treatments for some patients. It is hoped that the care delivery model, adaptations and resources developed as part of the BOB PEACE implementation will be adopted more widely to benefit many more autistic children, young people, adults and families struggling with EDs.
Eating disorders and their treatment present many ethical dilemmas. These are severe mental illnesses that have considerable consequences on all areas of sufferers' lives. Eating disorders are associated with reduced quality of life, high carer and societal burden and significant mortality. Whilst treatments evolve, it is widely acknowledged that our understanding of these conditions and effective treatment pathways is frustratingly inadequate. Eating disorders are philosophically perplexing in that they are experienced as part of the self and can become highly valued coping mechanisms. As a result, many patients will at some point deny aspects of their condition and avoid or refuse treatment. How should we approach challenging questions such as the following? Should treatment be enforced? Can a patient decide? Is coercion ever acceptable? Should patients be assisted in dying? An exploration of ethical principles can provide a framework, but the complexities of individual circumstances require a comprehensive, compassionate and flexible approach to these most fundamental issues. Ethical considerations must always be kept at the forefront of clinical decision-making.
