Tips for feeding or eating disorders in adults

• The restriction of eating gives a temporary impression of being in control, but this leads to ill health, so it is maladaptive.
• For some, restrictive eating, bingeing and/or other compensatory behaviours can be an attempt at managing emotions arising from uncertainty or any other difficult feelings.
• Many of the behaviours typical of FEDs can bring a sense of relief or safety in the short term but can then take on a life of their own, superseding the original ‘benefits’ for the person.
• When the illness takes over, the person loses control over the illness behaviours. For this reason, factors that contribute to a FED starting may not be the same as those that are keeping the disorder going.
• Each of the FEDs has its own psychology and course, although there is some overlap across diagnostic categories.
• For example, in anorexia nervosa (AN) the negative spiral of eating disorder behaviours is accelerated by the impact of starvation and deficient nutrition on the brainA rigidity can set in. It can seem like an ‘addiction’ and relationships can suffer. For example, avoidance of eating together or distress responses around food all impact relationships with close others.

• People with anorexia nervosa often feel more agitated after eating and calmer when they don’t eat.
• People who binge often experience temporary calming when binging, but distress returns soon afterwards.

• Be aware that mental capacity (in terms of the Mental Capacity Act) may be intact for other issues, BUT thinking and hence mental capacity may be severely impaired for FED related issues.

• For example, when the eating disturbances are related to particular thoughts/cognitions, treatment might differ from when food avoidance is driven by sensations/sensory experiences linked to food.

• Everyone involved in their care to communicate with each other, respecting appropriate agreements for confidentiality and information sharing..
• To be listened to, their views to be heard and wishes taken into account
• Treatment to be based on the possibility of recovery.
• Professionals and family/carers not to give up on them.
• Access to skilled professionals in the community, who have expertise in feeding or eating disorders and understand wider mental health issues (mood, anxiety, etc.) and how this interacts with food and eating
• Treatment to be collaborative with involvement in setting up their care plan and treatment goals.
• If the person needs inpatient treatment, for their community team to remain involved in their care throughout and help seamless transition back home.
• Possibility of self-referral to dedicated community eating disorder services or other appropriate services.
• Advice and support available for their family and carers own mental health and wellbeing needs.

• To receive support to help their loved one with a FED, regardless of whether their loved one is getting treatment or not.
• For services to understand that carers who are partners and carers who are parents may have different needs, and for the right level of information and support to be provided to each group.
• For services to understand the distress they can experience and support them to get help with their our own mental and physical health.

• That people with FEDs have equal access to treatment regardless of age, personal characteristics and socioeconomic characteristics.
• That accurate information on FEDs is provided to those with eating disorders and, where possible, their family members or carers. This can include information on what eating disorders are, risks, and treatment options available.
• Being sensitive when discussing weight and appearance, and show empathy, compassion and respect – holding in mind that people with FEDs may be ashamed and anxious about sharing their difficulties.
• That family members/carers/close others are involved in treatment, as appropriate and with the patient’s consent.
• That care is coordinated when multiple services/professionals are involved. This includes collaboration across eating disorder teams, if someone is moving between services, and collaboration with other mental and physical health teams where these are involved in someone’s care.

Care for adults with AN should involve a specialist eating disorder service and include psychoeducation about the disorder; monitoring of weight, mental and physical health and any risk factors; be multidisciplinary and coordinated between services; and involve the person’s family or carers if appropriate.

There are three first-line recommendations for psychological therapy with adults with AN:

• Individual eating disorder focused cognitive behavioural therapy (CBT-ED)
• Maudsley anorexia nervosa treatment for adults (MANTRA)
• Specialist supportive clinical management (SSCM)

These treatments usually involve 20-40 sessions, mostly held weekly. Treatment primarily focuses on what is keeping the AN going now, with relatively less attention to early life events.

If CBT-ED, MANTRA and SSCM are all unacceptable or contraindicated, eating disorder focused focal psychodynamic therapy (FPT) can also be considered. This usually involves 40 weekly sessions.

Medication and dietary advice are not recommended as sole treatments for AN.

• BN-focused guided self-help should be considered as a first line option, usually involving a cognitive behavioural self-help manual and brief supportive sessions spaced over about four months.
• If guided self-help is unacceptable, contraindicated or ineffective after four weeks, individual eating disorder focused cognitive behaviour therapy (CBT-ED) should be considered. This typically consists of up to 20 sessions over 20 weeks.
• Treatment for BN has a limited effect on body weight and is most effective when people are able to make behavioural changes over the first four weeks.
• Provide information about:
  • regulating body weight
  • dieting
  • the adverse effects of attempting to control weight with self-induced vomiting, laxatives or other compensatory behaviours
  • the ineffectiveness of vomiting or abusing laxatives as a strategy to lose weight 
  • useful information sheets can be found at https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Disordered-Eating or see the other resources at the end of this tip sheet

• Treatment for BED focuses on regular eating with reduction of binge eating. This may prevent further weight gain but does not necessarily result in weight loss, and weight loss is not a therapy target in itself. This should be explained to patients.
• BED-focused guided self-help should be considered as a first line option, usually involving a cognitive behavioural self-help manual and brief supportive sessions spaced over about four months.
• If guided self-help is unacceptable, contraindicated or ineffective after 4 weeks, group eating disorder focused cognitive behaviour therapy (CBT-ED) should be considered. This typically consists of 16 sessions over 16 weeks.
• If group CBT-ED is not available or is declined, consider individual CBT-ED (16-20 sessions).

• Needs to target the main factors underlying and maintaining the eating disturbance – these may vary between individuals.
• The primary treatment modality will be a form of psychological intervention aimed at changing eating behaviour.
• Most promising psychological interventions include adapted cognitive behavioural approaches and behavioural techniques.

• It is recommended that treatment for OSFED is based on the recommended treatments for the FED it most closely resembles. Often this means using CBT-ED.
• Treatment of all FEDs should be multidisciplinary with consideration of medical and dietetic monitoring and management alongside psychological therapy.
• There are other promising treatments being evaluated for use with FEDs, including cognitive analytical therapy (CAT), dialectical behaviour therapy (DBT), schema therapy and interpersonal therapy. Evidence is still emerging for these options.

• Good quality psychoeducation and self-help resources can be helpful for all FEDs. See ‘Tip Sheet 1 – What to be aware of’ for information on the starvation effects associated with eating disorders – these can be especially helpful to share. Tip Sheet 1 also includes other suggested topics for psychoeducation.
• For patients who are not willing to engage with a specialist eating disorder service, or who are waiting to be seen by a specialist eating disorder service, self-help material may allow for improvements in FED symptoms.
• There is a strong evidence base supporting the use of ‘Overcoming Binge Eating’ (C. Fairburn) and ‘Getting Better Bit(e) by Bit(e)’ (U. Schmidt, J. Treasure & J. Alexander) for self-help treatment of binge/purge type eating disorders, including bulimia nervosa and binge eating disorder.
• The self-help modules available for free download from https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Disordered-Eating are also based on cognitive behavioural therapy for eating disorders, and are suitable for all eating disorder diagnoses.

• This may involve eating disorder focused treatment being adapted to take into account the other difficulties; treatment for the other mental health difficulties being adapted to take into account eating disorder symptoms; or sequential treatment (treating the FED first and then the other difficulties, or vice versa).
• Refer to the relevant NICE guidelines for the other presenting difficulties.
• For patients with a FED and personality disorder, consider if the eating disorder symptoms are best accounted for by the personality disorder. For example, someone with a diagnosis of emotionally unstable personality disorder/borderline personality disorder may binge eat and purge as part of a range of behaviours used in response to extreme emotional distress. In these instances, eating disorder treatment should be planned in collaboration with other team/s involved in the patient’s care and with consideration of treatment for the personality disorder.

• Trauma may include early adverse childhood experiences, or traumatic events in adolescence or adulthood. Sometimes they may give rise to a diagnosis of post-traumatic stress disorder but not always.
• Eating disorder symptoms can be one way that someone tries to cope with the effects of past trauma. Restriction, binge eating and purging can all ‘numb’ emotions or distract from trauma-related thoughts or feelings.
• First-line eating disorder treatments should still be offered to those with trauma, but care should be taken to understand how FED and trauma symptoms interrelate. Sometimes, additional trauma-focused treatment may be required, or FED symptoms may be addressed as part of trauma treatment.

• Reasonable and appropriate adaptations are required for people with vulnerabilities and additional needs.
• Autism is particularly common amongst people with anorexia nervosa and avoidant restrictive food intake disorder. The PEACE pathway offers guidance and support for tailoring eating disorder treatment to autistic people (https://www.peacepathway.org/).

• Each person will have different factors that help them work towards recovery. These ‘motivators of recovery’ may include:
  1. wanting to feel better physically
  2. returning to leisure activities
  3. getting back to education or work
  4. spending more time with friends and family or have improved relationships; for some people, wanting to start a family/have children can be a motivator 

• The therapist needs to understand them in order to help the person with these difficulties.

• Stabilise physical state, address acute nutritional deficits, engage, and provide knowledge via good quality psychoeducation.
• Explain the nature of the condition.
• Highlight its impact on the brain, body and mind.
• Explore reasons to change – what motivates the person to want to tackle their FED? Also pay attention to worries about change – what does the person value about their FED or fear losing if they change?
• Help the person to start to change their eating habits; this may include work on regular eating, eating a wider range of foods, eating more appropriate portions, and riding out urges to binge and purge.

• Address the person’s need to feel safe, feel in control, and their emotional management strategies that can include eating disordered behaviours to cope with anxiety and distress.
• Be mindful that downplaying or denial of symptoms is common and may be linked to shame, guilt or even terror of consequences of making changes. Find ways to overcome this collaboratively
• Address impacts of the FED on relationships.
• Keep in mind that interventions or management should be based on holistic person-centred formulation, not a single issue like weight or ‘diagnosis’.

• In 2022, Medical Emergencies in Eating Disorders (MEED) replaced MARSIPAN-Management of Really Sick Patients with Anorexia Nervosa.
• Tip Sheet 3 – ‘What medical interventions’ gives more information on the MEED guidelines and managing medical risk.

• Particularly between services.
• Students who move between ‘home’ and ‘university’ locations are entitled to register with a GP in each area (one as a primary GP and one as a temporary GP) and access eating disorder care in each area. Eating disorder services should take care to communicate with each other and with both GP surgeries, with clear arrangements for managing risk.
• Appendix 4 of the Medical Emergencies in Eating Disorder (MEED) guidelines provides a template to facilitate a clear handover from one clinical service or area to another.

• Review treatment progress regularly.
• Use standard symptom scales, impairment scales, patient and family feedback on progress and agreed goals of intervention.
• Use appropriate standard outcome measures such as the EDE-Q for anorexia nervosa and bulimia nervosa, the PARDI-AR-Q, for ARFID.
• Intervention goals should be regularly reviewed.

• When prescribing for people with an eating disorder, professionals need to consider the impact of malnutrition and purging or related behaviours on the effectiveness of medication.
• Medication can play a useful adjunctive role in the management of eating disorders for a range of reasons, especially for comorbid disorders like depression and/or anxiety disorder. Often this takes the form of a selective serotonin reuptake inhibitor (SSRI).
• However, medication should not be used in isolation, but as part of a holistic management plan.
• In severe anorexia nervosa, Olanzapine has been used, especially early in treatment, to help with extreme anxiety, making it easier to adhere to the meal plan. Use the lowest dose possible because of the risk of physical complications.
• Consider the risk of the side-effects in physically compromised patients.
• ECG monitoring needs to be offered to people with an eating disorder where medication can compromise cardiac function, for example, those with bradycardia below 40 bpm, hypokalaemia or a prolonged QT interval.
• Those with inadequate diet should be encouraged to take an oral multivitamin and multi mineral supplement until their diet meets daily dietary reference values.
• Oral or transdermal oestrogen therapy should NOT be routinely offered to treat low bone mineral density in anorexia nervosa, the focus instead should be on assisting the return of appropriate eating habits and weight gain through psychological interventions.
• A bisphosphonate may be an option in women with long-term low body weight in anorexia nervosa, and low bone density for their age. However, it’s important to consider the risks and benefits, particularly if they might want to have children in the future. This is because we don’t yet know for certain whether bisphosphonates might affect an unborn child.

• Effective liaison and coordinated care are critical.
• In cases of emergency, the local eating disorder service should be contacted for advice and management support.
• If a number of services are involved simultaneously then clear communication and a shared care plan needs to be in place outlining responsibility of each service to deliver their part of the care plan
• Care needs to be multidisciplinary and coordinated. An eating disorder service team is likely to include clinical psychologists, other psychotherapists, dietitians, family therapists, nurses, psychiatrists and administrators.
• When a seriously ill patient with a FED is admitted to a medical facility, psychiatric input from either eating disorder or liaison teams should occur alongside medical input so that physical and psychological problems are managed concurrently.

• A ‘public health approach’ to eating disorders is recommended in all aspects of data collection, training, academic funding and service delivery.
• Eating disorders should be a central consideration to public health policy on obesity and mental health.
• General rebalancing of provision, from a focus on inpatient services to expansion of community-based services to access treatment earlier, and closer to home.

Image source: NHS England and National Collaborating Centre for Mental Health, 'Adult eating disorders: community, inpatient and intensive day patient care: Guidance for commissioners and providers'

• Comprehensive person-centred holistic care plans (NICE QS 1) should be in place.
• Dedicated, community-based eating-disorder services have been shown to improve outcomes and cost-effectiveness.
• Early intervention can improve outcomes. The FREED pathway (First episode Rapid Early intervention for Eating Disorders) is an evidence-based early intervention model for emerging adults with an eating disorder of up to three years duration. Resources can be found at freedfromed.co.uk.
• Services have best outcomes when they are based on continuous improvement- drawing on best evidence, open to participation of experts by experience, and learning from outcomes.
• Avoid commissioning for severity in isolation as it mitigates against necessary early intervention in eating disorders.
• For eating disorder care (this does not preclude need for admission for physical care needs) clinicians should keep in mind that there is no evidence that inpatient treatment has any advantages over providing treatment in the community. With the exception of life-threatening physical health risks, outpatient care should generally be offered before inpatient treatment is considered.

• 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
10. Treasure J, Duarte TA, & Schmidt U. Eating disorders. Lancet, 395, 899-911 (2020). https://doi.org/10.1016/S0140-6736(20)30059-3.
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