Eating disorders
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
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Abstract |
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 TOP Abstract What does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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Although classification of eating disorders is relatively recent, cases of female anorexia have been recorded since the eleventh century. Then, the intentional self-starvation of women was thought to result from religious yearnings resulting in these women being termed ‘fasting saints’. Freud recorded a case of bulimia nervosa in a female patient in the nineteenth century. There are currently three recognized eating disorders: anorexia nervosa, bulimia nervosa and binge eating disorder. Many more people have disordered eating patterns that show features of these conditions but do not meet the criteria for diagnosis.
An eating disorder is a complex compulsion to eat, or not eat, in a way that disturbs physical and mental health. On the surface, eating disorders appear to be about food, or rather misuse of food, but there are usually much more complex emotional issues underlying them. These disorders are common, may be difficult to detect and usually present to GPs either directly or indirectly. They can affect sufferers over a period of years, or even lifelong, and may have devastating consequences both for the sufferers and their families. This article aims to give GPs an understanding of the epidemiology, presenting features and management of these conditions.
Curriculum statement 13 (Care of people with mental health problems) highlights eating disorders as common and important conditions. It requires GPs to:
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Epidemiology and statistics |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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At least 1.1 million people in the UK are affected by an eating disorder, with young people in the 14–25 age group being most at risk of developing this type of illness. Incidence is increasing. Girls and women are 10 times more likely to suffer from anorexia or bulimia than boys and men. Binge eating disorder is equally common among men and women.
Women
Among women, as many as one woman in 20 has eating habits that give cause for concern and 1% are affected by eating disorders. Women tend to overestimate their body size. In one study, 11% of young women surveyed were overweight, but 50% classified themselves as such. In contrast, men tend to perceive themselves as smaller than they actually are. This mismatch of body image and actual body size may explain the difference in incidence of anorexia and bulimia seen between women and men.
Other risk factors for the development of eating disorders in women include the following:
- Ethnicity: People of Asian or Afro-Carribbean origin are less likely to develop eating disorders than other ethnic groups.
- Weight and shape-related issues: Women who have concerns about their weight (e.g. models or dancers) and women who diet or have a pre-morbid history of obesity are more prone to eating disorders. Women who have had eating difficulties in childhood also have a higher risk of eating disorders.
- Genetics: Twin studies suggest that there is a substantial genetic effect for the liability of people to develop both anorexia and bulimia nervosa. If one of a pair of identical twins develops anorexia, the other has a 50% chance of developing the same. People who have close relatives with bulimia are four times more likely to develop the disease than people who do not.
- Sexual abuse: Three in every 10 women with anorexia have a history of sexual abuse in childhood.
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Men
Men account for between 1% and 5% of patients with anorexia nervosa after puberty, though before puberty, about half of those diagnosed are male. Eating disorders in males often go unrecognized or undiagnosed due to reluctance among males to seek treatment for these stereotypically female conditions.
Although most of the risk factors for eating disorders are common to both men and women, men with anorexia or bulimia tend to present later than women and have a higher level of pre-morbid obesity. An additional risk factor for anorexia or bulimia for males is homosexuality. Social pressures for thinness impact less on males; however, the growth of the fitness industry and the explosion of male lifestyle and fitness magazines may change this.
Children
In 2006, NHS Hospitals treated 58 children under the age of 10 years for eating disorders. Only 1% of children feel that they can talk to their parents about their eating-related concerns, 92% feel that they cannot tell anyone.
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Detection of eating disorders |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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Some patients with eating disorders will recognize the problem themselves and seek help directly from a GP. More often patients are brought to see a GP by a worried relative or friend. However, eating disorders often go undiagnosed for years, or remain hidden forever. Have a high index of suspicion.
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Two screening questions have been shown to be effective for detecting eating disorders (Box 1). A positive response to either or both of the questions should prompt further questioning of the patient about eating habits. Target groups for screening include the following:
- Young women with low body mass index compared with age norms
- Patients consulting with weight concerns who are not overweight
- Women with menstrual disturbances or amenorrhoea
- Patients with gastro-intestinal symptoms
- Patients with symptoms or signs of starvation—sensitivity to cold and/or hypothermia, delayed gastric emptying, constipation, hypotension and/or bradycardia
- Patients with physical signs of repeated vomiting—pitted teeth and/or dental caries, general weakness, cardiac arrythmias, renal damage, electrolyte disturbance (particularly hypokalaemia), recurrent urinary tract infection or epileptic fits
- Children with poor growth
- Young people with type 1 diabetes and poor treatment adherence
Box 1. Screening questions for eating disordersDo you worry excessively about your weight?
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Features of anorexia nervosa |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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Anorexia nervosa affects 1–2% of women aged between 15 and 30 years. Ninety percent of those who suffer from anorexia nervosa are female. Features of anorexia usually begin in adolescence with peak prevalence between the ages of 16 and 17 years. The number of recorded cases of anorexia has increased steadily over the past 10 years, but it is not clear how much of this is due to a true increase in incidence of the condition and how much is due to increased detection.
Diagnosis
In the UK, diagnosis of anorexia is usually made based on the World Health Organization ICD-10 classification of diseases. Box 2 lists the diagnostic criteria for anorexia nervosa. Patients tend to have a set daily calorific intake, for example 600–1000 calories and may employ strategies such as bingeing and vomiting, purging or excessive exercise to try to lose weight. Depression and social withdrawal are common as are symptoms secondary to starvation.
Box 2. ICD-10 diagnostic criteria for anorexia nervosa
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Management
Check the patient's electrolytes and refer to a specialist eating disorders clinic (if available) or the specialist psychiatric services. Specialist treatment involves family therapy for adolescents, psychotherapy and possible admission for refeeding.
Give both patients and other family members ongoing support and information (Box 3). BEAT (Beating Eating Disorders) provides both patients with eating disorders and their carers with information and advice through its website and helpline. The Disordered Eating website also provides helpful information for sufferers and other family members.
| Box 3. Information and support for patients with eating disorders and their carers Beating Eating Disorders (BEAT)  : 0845 634 1414 (adults); 0845 634 7650 (youths), website: www.b-eat.co.uk.Disordered Eating Website: www.disordered-eating.co.uk.
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Many patients with anorexia nervosa have compromised cardiac function. Avoid prescribing drugs that adversely affect cardiac function—such as antipsychotics, tricyclic antidepressants, macrolide antibiotics and some antihistamines. If prescribing is essential, then follow the patient up with ECG monitoring.
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Outlook
About 40% of patients with anorexia recover completely, 30% continue to experience the illness long term and 5% die from their condition. Offer patients with enduring anorexia nervosa, not under secondary care follow up, an annual physical and mental health check.
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Features of bulimia nervosa |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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Bulimia affects 1–2% of women at any time in the UK and around 4% (and up to 8%) of women will suffer an episode of bulimia in their lifetime. It is much less common among men. Onset is usually in the teenage years, with a peak age of 18–19 years, and bulimia is rare before the age of 13.
Diagnosis
Box 4 lists the ICD-10 diagnostic criteria for bulimia nervosa. Like anorexia, people with bulimia have a self-image unduly influenced by body shape. However, people with bulimia have normal menses and normal weight. If they have low weight (less than 85% of their expected weight), then they are classified as having anorexia rather than bulimia.
Box 4. ICD-10 diagnostic criteria for bulimia nervosa
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People with bulimia have recurrent episodes of binge eating, far beyond normally accepted amounts of food. To compensate for this and prevent weight gain, they employ strategies such as vomiting, and use of laxatives, diuretics and/or appetite suppressants. Bulimics can be subdivided into those that purge and those that just use fasting and exercise to control their weight.
Management
Check the patients’ electrolytes. Many patients with bulimia can be successfully managed in primary care. Provide both sufferers and other family members and carers with ongoing information and support, including self-help information (Box 3).
Effective primary care interventions include evidence-based self-help programmes such as the ‘Overcoming Bulimia’ CD-ROM available from website www.calipso.co.uk, and/or antidepressant medication. Fluoxetine 60 mg once daily is the drug of choice. For patients who are vomiting, try to reduce the acid in the oral environment by limiting acid containing foods such as oranges and vinegar. After vomiting, advise patients to use a non-acid mouthwash and avoid brushing their teeth. Where laxative abuse is present, educate patients that laxatives do not significantly reduce calorie absorption. Advise patients to gradually reduce laxative intake.
If primary care management is unsuccessful, then consider referral to a specialist eating disorders clinic (if available) or the specialist psychiatric services. Cognitive behavioural therapy may help.
Outlook
Studies show that 50% of people with bulimia have recovered within 10 years of diagnosis, while 20% still have bulimia and 30% are partially recovered. Approximately 5% of bulimia sufferers go on to develop anorexia nervosa. Unlike anorexia, mortality rates from bulimia are very low.
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Features of binge eating disorder |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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It is thought that binge eating disorder is more common than other eating disorders, affecting
2% of adults. Not all, but most sufferers are obese, weighing >20% more than expected for their height and gender and it is thought that 10–15% of mildly obese people enrolled in weight loss programmes have binge eating disorder. Women are slightly more likely to have binge eating disorder than men in a ratio of approximately 3 to 2. Binge eating disorder is strongly associated with depression and about half of all sufferers experience a significant bout of depression at some point in their lifetime.
Diagnosis
Binge eating disorder is a pattern of consumption of large amounts of food, even when a patient is not hungry. It is usually associated with obsessive feelings about food and body image, feelings of guilt and/or disgust about the amounts consumed and/or a feeling of lack of control. Currently the ICD does not include binge eating disorder as an official diagnostic category. However, binge eating disorder is recognized as a distinct disorder in the NICE Guidance on Eating Disorders, and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) have proposed the criteria for diagnosis listed in Box 5.
Box 5. Proposed DSM-IV-TR diagnostic criteria for binge eating disorder
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Management
Most patients with binge eating disorder can be successfully managed in primary care. Provide both sufferers and other family members and carers with ongoing information and support, including self-help information (Box 3). Two management issues need to be addressed in these patients concurrently:
- Treatment of obesity
- Treatment of binge eating episodes
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High-risk groups |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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Patients who are pregnant or have diabetes mellitus are particularly at risk of complications if they have co-morbid eating disorders. Refer early for specialist support and ensure everyone involved in care is aware of the eating disorder.
Key points
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References |
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TOPAbstractWhat does the GP...Epidemiology and statisticsDetection of eating disordersFeatures of anorexia nervosaFeatures of bulimia nervosaFeatures of binge eating...High-risk groupsReferences |
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BEAT (Beating Eating disorders). Website: www.b-eat.co.uk/Home [date last accessed 16.12.2007].
Disordered Eating. Website: www.disordered-eating.co.uk/ [date last accessed 16.12.2007].
Kendrick T, Simon C. Oxford General Practice Library: Mental Health (2006) Oxford: Oxford University Press. ISBN 978-0-19-857057-8.
NICE Full guideline. Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. (2004) Accessed via www.bps.org.uk/downloadfile.cfm?file_uuid=C1173310-7E96-C67F-D396-ADF1B891F5A3&ext=pdf [date last accessed 23.09.2008].
RCGP. Curriculum statement 8: Care of children and young people. Accessed via.
RCGP. Curriculum statement 13: Care of people with mental health problems. Accessed via.
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