Tips for feeding or eating disorders in adults

• The earlier someone is able to access treatment or support for their FED, the greater chance they have of making a full and sustained recovery.
• Whilst early intervention is important, treatment should also be offered to those who have been unwell with a FED for a long time. Full recovery is possible even after many years of illness
• For adults who are not able to think about full recovery, treatment may facilitate improvements in health and quality of life.
• FED symptoms may be obscured due to apparent social norms e.g. vigorous exercise in someone overweight, restricting certain food types, weight loss in someone who is overweight…look out for compulsive unhealthy or extremes of behaviour including in adults who are not underweight or overweight.
• Look at the slide and think about the risk factors listed that contribute to the development of eating sBeware of outward appearance. It may not always be obvious that someone has a FED, nor does someone have to be underweight to be suffering with a FED.

• While more people with FED are female, many boys and men also have the disorders Because this is not widely appreciated, males tend to be diagnosed later than females and this may reduce their chances of recovery.
• Be alert and know the person may be very unwell, much more so than they may first appear. For example, check their weight and rate of weight loss, their blood pressure and heart rate, their ECG, blood biochemistry, haematology, body temperature and nutritional status. More information is available in tip sheet III on medical investigations.

• Beware of focussing only on the psychological and missing the physical, or vice versa. Effective intervention must include both.
• There is no one single cause; each person will present slightly differently and may not have all the recognised symptoms for one FED. It is also common for FEDs to change over time. They are serious regardless of the specific symptoms being experienced.
• For treatment, you must look at each person as an individual and address both the physical and psychological impact.

• FEDs may occur at any age, of any ethnicity, gender or background.
• The median age of onset for all FEDs is age 18. Anorexia nervosa (AN) most often emerges in mid-adolescence with a median age of onset of 17 years. Bulimia nervosa (BN) most often emerges in late adolescence with a median age of onset of 18 years. Binge eating disorder (BED) can develop in childhood or adulthood and has a median age of onset of 20 years.
• Onset can occur in later adult years although new onset is relatively rare after age 30
• There is often a delay between onset of a FED and someone seeking help. This means that someone may first seek help for a FED in their 20s, 30s, 40s, 50s or beyond, even if onset was during adolescence.
• In older adults, depressive symptoms or cognitive decline may contribute to under-eating and weight loss that require careful differential assessment from a FED.
• Regardless of age, FED can interrupt relationships, education and work. This can complicate the recovery process during treatment.

• Anorexia nervosa significantly reduces quality of life and has one of the highest mortality rates for any mental health disorder.
• Death can result from suicide (20%), heart/cardiac-related events, severe electrolyte imbalance (e.g., low potassium levels), and extreme weight loss.
• Early detection and appropriate care make all the difference.
• Current expert opinion advises that:
  • Full recovery is possible; 
  • The sooner someone gets the treatment they need, the more likely they are to make a fast and sustained recovery;
  • A ‘wait and see’ attitude with young people who are developing a FED is not usually helpful;
  • The sooner someone with a FED starts an evidence-based NICE-concordant treatment the better the outcome
• First episode Rapid Early intervention for Eating Disorders (FREED) offers an evidence-based early intervention model for emerging adults aged 16 to 25 years with an eating disorder of less than 3 years duration (see www.FREEDfromED.co.uk).
• Be sure you get physical observations (blood pressure, heart rate, temperature), blood biochemistry, haematology and ECG results to ensure rapid and safe clinical decision making for those who are severely restricting food and rapidly losing weight, or who are engaging in multiple daily episodes of vomiting and/or laxative abuse.
• Initially appointments should be weekly and should include weighing of the patient, especially for people who are restricting their food intake (for example in anorexia nervosa and avoidant restrictive food intake disorder [ARFID] , but also sometimes other specified feeding or eating disorders [OSFED] and bulimia nervosa).

• FEDs affect the entire family, therefore family members play an integral role in treatment and should where possible be involved regardless of the patient’s age, although the way they are involved will differ for adults compared to children and adolescents.
• Family and carers are a great resource to support good outcomes, mobilise strengths and build collaboration. Family / carers may include parents, partners, siblings, children, close friends or other important members of someone’s support network.

• Studies define ‘remission’ and ‘relapse’ in different ways, which can make it difficult to compare treatment outcomes. However, half to two-thirds of adults who start treatment for their FED are likely to experience meaningful reductions in symptoms by the time their treatment ends.
• Better treatment outcomes are predicted by greater symptom change over the early weeks of treatment; it can be helpful to let patients know this, so they can make the most of their early treatment sessions.
• Cross-over from anorexia nervosa to bulimia nervosa is common, as is movement in and out of an ‘other specified feeding or eating disorder’ (OSFED) diagnosis.
• We know less about treatment outcomes for avoidant restrictive food intake disorder (ARFID) than the other FEDs – there are no comparable longitudinal studies at this stage.
• Comorbidity with anxiety and/or depressive disorders, trauma symptoms, autism, ADHD and/or personality disorders is common in adults with FEDs. Comorbidities should be considered when planning treatment. This could include adapting FED treatment to take into account other presenting difficulties; adapting treatment for other disorders to take into account the FED; or planning sequential treatment (treating the FED first or vice versa). The PEACE pathway website offers useful guidance on the treatment of FEDs for an autistic person (https://www.peacepathway.org/).

• People with anorexia nervosa and other FEDs might have great difficulty in seeing how unwell they are or may be in denial about their illness.
  • This can be despite having full clarity of thought and reasoning in their world outside their FED
• It is important to note that many people with FEDs have struggled with disordered eating and distress for many years before seeking help.
• The multidisciplinary team should focus on ensuring that the patient's health and safety come first.
• Specialist eating disorder services are used to working with people who are unsure if they have a problem or are reluctant to think about change.

Below is a short list, further information is provided in our Tip Sheet 2 What to look out for

• Low mood
• Stress hormones increase - cortisol goes up
• Sexual hormone levels are reduced; amenorrhea is one consequence in females and reduced sexual interest is common in males and females
• Difficulties with concentration and decision making, including focusing on small details, with difficulty seeing the ‘bigger picture’
• Social withdrawal / a reduced interest in socialising
• Physiological effects such as delayed gastric emptying, which means the person feels full quicker, even though the body is malnourished                             

• Starvation increases the drive to eat in some people, and can trigger food cravings and binge eating behaviour
• A negative cycle can occur with these changes in thinking, feeling, physical experiences and behaviour going on to make the eating disorder worse
• There are multiple other physical effects, including long-term effects like osteopenia (thinning of bones) and osteoporosis; please refer to what to look out for tips

• Accurate information can help people with FEDs make changes and reduce the distress they experience around eating disorder symptoms.
• Psychoeducation is also important for family members and carers.
• It can be particularly helpful to cover information on starvation effects, as people often don’t realise that low mood, anxiety, social withdrawal and other starvation symptoms are consequences of restrictive eating.
• For people who binge eat, psychoeducation on the ‘vicious cycle’ between restrictive eating and binge eating is important.
• Eating disorders are not all about food; FEDs can be a way of coping with difficult emotions, relationships or life events. People with restrictive FEDs may feel more. anxious/agitated/distressed/guilty before, during and after eating, and less anxious when they don’t eat
• People who binge eat or purge might experience temporary relief from challenging emotions and thoughts when bingeing or purging, but distress and shame may return afterwards.

• Anorexia nervosa (AN)
• Bulimia nervosa (BN)
• Avoidant restrictive food intake disorder (ARFID)
• Binge eating disorder (BED)
• Rumination-regurgitation disorder (RD)
• Pica
• Other specified feeding or eating disorders (OSFED)
• This includes purging disorder (purging without bingeing). Be aware this can occur in people with type 1 diabetes, when insulin omission is used to influence weight. This is known as Type 1 Diabetes and eating disorders (for more information see resources including MEED guidance)
• It also includes ‘atypical or ‘subthreshold’ AN, BN and BED
• An eighth category in ICD11 is for ‘unspecified feeding or eating disorders’ (UFED)
• For more on each type of disorder see our tips on “What to Look Out For”

• Body image distortion/dissatisfaction is a core driver of anorexia nervosa/bulimia nervosa.
• For other FEDS like binge eating disorder and related OSFED presentations, it is sometimes present but not the main issue.

• This may also be required in rumination-regurgitation disorder, ARFID, presentations of OSFED and bulimia nervosa where someone is heavily restricting their food intake and/or has lost a lot of weight.

• some occur long before the onset of a FED, some are close to onset and are triggers, and some maintain the problems once started.

• These can be biological, psychological, social-cultural context and media related, and developmental-neurodevelopmental.

• Predisposing factors: There is a strong genetic component to FEDs, with heritability estimates being in the region of 50-75% for anorexia nervosa (AN), bulimia nervosa (BN) and avoidant restrictive food intake disorder (ARFID). Estimates for binge eating disorder (BED) are around 40-45%. FEDs show genetic correlations with other psychiatric disorders (particularly anxiety disorders) but also metabolic disorders. Related to this, a family history of eating disorders is a known predisposing factor (likely due to both genetic and environmental effects).
• Other predisposing factors include addiction, mood disorders, diabetes, personality traits (including obsessive-compulsive traits, particularly in AN, and impulsive / emotionally unstable traits, particularly in BN), relationship problems, overvaluation of shape, weight and food, difficulty managing emotions, sport activities like marathon running or ballet, brain changes being identified in studies, having a family member with eating disorder, higher weight, social media, rigidity of thinking (AN), risk avoidance (AN), perfectionism (AN and somewhat BN), low self-esteem (all), general anxiety (all). 50% of people with AN have an anxiety disorder prior to developing AN.
• Triggers: stressful life events and losses - the pandemic appears to be an example, with increased rates of eating disorders after COVID-19. In addition, traumas, including all forms of abuse, food allergies and or coeliac disease, sport activities, other people’s comments about weight or shape, social media, advertising of ‘ideal’ body imagery.

• BEAT Tips Poster
• BEAT leaftlet: Seeking treatment for an eating disorder? The first step is a GP appointment.
• BEAT carers booklet: Eating disorders: a guide for friends and family
• Type 1 diabetes with an eating disorder: more information
• BEAT elearning for nurses (for all ages, not child and young person specific - Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. To access the elearning in the elfh Hub directly, please visit the links below.
  • Screening and Assessments
  • The Impact of Starvation
  • Sensitive Communication

• Medical Emergencies in Eating Disorders (MEED). Guidance on recognition and management. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 1: Summary sheets for assessing and managing patients with severe eating disorders. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Medical Emergencies in Eating Disorders. Annexe 2: What our National Survey found about local implementation of MARSIPAN recommendations. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 3: Type 1 diabetes and eating disorders (TIDE). RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)

• Eating Disorders: Recognition and Treatment NICE Guideline (NG69) 2020
• Eating Disorders Quality Standard (QS175) 2018
• Adult eating disorders: Community, inpatient and intensive day patient care. Guidance for commissioners and providers

• Ignoring the alarms: How NHS eating disorder services are failing patients. Presented to Parliament pursuant to Section 14(4) of the Health Service Commissioners Act 1993, Ordered by the House of Commons to be printed on 6 December 2017.

• Eating Disorders from the Inside Out: Laura Hill at TEDxColumbus

From MindEd session Eating Disorders: Further Information for Professionals:

• Talk ED
• Beat (beating eating disorders)
• Centre for Clinical Interventions
• Faculty of Eating Disorders Royal College of Psychiatrists
• F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders)
• Men Get Eating Disorders Too (MGEDT)
• National Institute for Health and Care Excellence guidance for Eating disorders: recognition and treatment

1. Bulik CM, Coleman JRI, Hardaway JA et al. Genetics and neurobiology of eating disorders. Nat Neurosci, 25, 543-554. doi: 10.1038/s41593-022-01071-z. 
2. Galmiche M, Déchelotte P, Lambert G, & Tavalacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutri, 109, 1402-1413 (2019).  
3. McClelland, J., Simic, M., Schmidt, U., Koskina, A., & Stewart, C. (2020). Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder. BJPsych Open, 6(3), E37
4. Neale J, Pais SMA, Nicholls D, Chapman S, Hudson LD. What Are the Effects of Restrictive Eating Disorders on Growth and Puberty and Are Effects Permanent? A Systematic Review and Meta-Analysis.J Adolesc Health. 2019 Nov 23. doi: 10.1016/j.jadohealth.2019.08.032.
5. NICE guideline (NG69) 2017. Eating Disorders; recognition and treatments. 
6. Nicholls D, Becker A. Food for Thought: Bringing Eating Disorders out of the shadows. BJPsych 2019 Jul 26:1-2.
7. Petkova H, Ford T, Nicholls D, Stuart R, Livingstone N, Kelly G, Simic M, Eisler I, Gowers S, Macdonald G, Barrett B, Byford S. Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study. BMJ Open 2019; BMJ Open 2019 Oct 22;9(10)
8. Smink FRE, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatry, 26, 543-548 (2013). doi: 10.1097/YCO.0b013e328365a24f.
9. Solmi, M., Radua, J., Olivola, M. et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27, 281–295 (2022). https://doi.org/10.1038/s41380-021-01161-7
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11. Vall E & Wade TD. Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis. Int J Eat Disorders, 48, 946-971. https://doi.org/10.1002/eat.22411 

Eating disorders training for health and care staff

This suite of training was developed in response to the Parliamentary and Health Service Ombudsman (PHSO) investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report titled Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients(PHSO, 2017).

It is designed to ensure that health and care staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It is the result of collaboration between eating disorder charity Beat and Health Education England with key partners.

Eating disorders training for medical students and foundation doctors

This eating disorders training is designed for medical students and foundation doctors. The two sessions will take around 20-30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. The sessions also provide good preparation for those who go on to participate in medical simulation training on eating disorders.

• Signs, Symptoms and Causes
• Practical Requirements

Eating disorders training for nurses

This eating disorders training is designed for the nursing workforce. Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Screening and Assessments
• The Impact of Starvation
• Sensitive Communication

Eating disorders training for GPs and Primary care workforce

This eating disorders learning package is designed for GPs and other Primary Care clinicians. The two sessions will take around 30-40 minutes each to complete and includes additional learning resources for those looking to further increase their knowledge. 

• GPs and Primary Care: Understanding Eating Disorders
• GPs and Primary Care: Assessing for Eating Disorders

Medical Monitoring in Eating Disorders learning for all healthcare staff who are involved in the physical assessment and monitoring of eating disorders

The eating disorders learning package for Medical Monitoring is designed for primary care teams, eating disorder teams or other teams who are monitoring the physical parameters of a person with an eating disorder. The session will take around 30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Medical Monitoring in Eating Disorders