1. The eating disorder is rarely the presenting complaint.
Eating disorders are increasing in prevalence. The number of people being diagnosed and entering inpatient treatment for eating disorders in England alone has increased at an average rate of 7% year on year since 2009, but many GPs will say that they don’t see many patients with such symptoms.¹ The likelihood is that if you’re not seeing the symptoms, it’s because you’re probably not asking about them enough.
Patients may present primarily with mood disorders, self-harm or amenorrhoea. They may also present with fatigue or ask about weight gain as a side-effect during contraceptive pill checks.
Being alert to the possibility of an eating disorder is a step in the right direction towards diagnosis and support.
2. Ambivalence towards the diagnosis and treatment is extremely common.
You should expect patients with eating disorders to be reluctant to accept that they have a health problem related to food, and to be slow to take up offers of referral and treatment. Address their original presenting complaint, and gradually introduce the questions around food, before suggesting a possible diagnosis.
A non-judgmental and gentle approach is key to building a trusting relationship that will be essential to helping your patient in the long term. As a GP, you don’t need to diagnose exactly which eating disorder they have, but it is more important to refer for early assessment if you are concerned.
3. Caring for a patient with eating disorders is more like a marathon than a sprint.
Patients often present several times with issues that are related to the eating disorder, such as having reflux secondary to self-induced purging, before they are able to talk about the eating issues at the centre of their disorder.
Building the relationship between GP and patient over time is crucial, especially as the patient may well not attend the specialist appointments that you have arranged, even if they agreed to referral.
GPs will need to be tolerant of the slow progress, and accept that many patients will not fully recover, but that we can make their lives more comfortable and minimise their health risks wherever possible.
4. Earlier intervention leads to better outcomes.
Eating disorders, in particular anorexia nervosa, have the highest mortality of any mental health condition after suicide or starvation. Statistically, 15 is the commonest age for admission with eating disorders in girls, whereas the most common age in boys is 13. Some 76% of these admissions are for anorexia. The NICE guidance is very clear that early intervention is a priority.²
5. Introductory questions on the issue are still worthwhile.
GPs often feel awkward about introducing the topic of eating disorders, and good introductory questions might be:
• Do you worry about your weight? Maybe too much?
• You look quite slim. Does that worry you at all?
• Do you spend a lot of time thinking about your weight and what you eat?
Even if this does not lead to significant progress at the time, you will have planted the seed of a thought, and hopefully the patient will feel able to come back to you when they feel ready to make changes or seek help.
A formal questionnaire such as SCOFF may also be helpful and this is featured in the Pulse Toolkit app, available to download for iOS and Android devices (pulsetoday.co.uk/toolkit).
Alternatively, to rule out an eating disorder, the patient will be likely to answer ‘no’ to ‘does your weight affect the way that you feel about yourself?’, and answer ‘yes’ to ‘are you satisfied with your eating patterns?’
6. Ask about eating behaviours.
Key to diagnosis is to understand if the patient:
• Has lost control over their eating.
• Avoids food and restricts calories.
• Binges (where they consume significant and excessive amounts of food, often carbohydrates, in one sitting until they feel uncomfortably full).
• Compensates for excess calorie intake with purging (vomiting), laxative or diuretic use, or through excess exercise.
• Eats in secret.
Such information is not only important for diagnosis, but also for risk assessment.
7. Ask about mood, self-harm and physical symptoms, and assess risk.
Risk is high with eating disorders, from fluid loss, starvation and malnutrition, through to osteoporosis and arrhythmias. In anorexia, rate of weight loss is important and a patient losing more than 1kg per week requires urgent assessment.
In bulimia, frequency of vomiting may indicate a risk of electrolyte imbalance. As a rule of thumb, vomiting more than three times a week should prompt weekly blood tests for urea, electrolytes and creatinine.
8. Investigations in primary care may include bloods, ECG and referral for DXA scan.³
Key blood tests include: FBC, U&E and creatinine, creatine kinase, glucose, LFT, MG, PO4, calcium, and bicarbonate. A TFT and ESR should also be considered on the first occasion to rule out any other conditions.
An ECG to check for bradycardia or prolonged QT interval should be arranged if the patient’s BMI is below 15, or if they take medications that could affect the QT interval.
A DXA scan is recommended if the patient has had anorexia for more than two years or has been amenorrhoeic for more than 12 months. This is to look for osteopaenia or osteoporosis.
9. Refer for psychological therapies and assessment of need for medication.
The mainstay of treatment for all eating disorders is psychological therapy. These can include family therapy, CBT and group work such as pre-contemplation groups for those who are most ambivalent about change.
In bulimia, fluoxetine 60mg has been shown to have some benefit in reducing the urge to binge, and this may also help with low mood and anxiety.
Medications, such as the combined oral contraceptive pill and calcium supplements, may help with bone protection, and PPIs may be useful for symptom relief of acid reflux. Iron and potassium supplements may also be indicated after blood results come back. It is wise to seek advice from specialist local teams wherever possible.
10. Resources are available for professionals, patients and carers, including books, websites and charities.
There is excellent support available through the B-eat, and Anorexia Bulimia Care charities, as well as via the Succeed Foundation, which also supports carers.
Many useful resources have been brought together on the Network-ED website (see resources), for ease of access for busy primary care professionals. Organisations such as Student Minds and Men Get Eating Disorders Too run groups and offer local support. You can link to these through your own practice websites to help support your patients.
New NICE eating disorders guidelines will be launched in 2017.
Dr Dominique Thompson is a GP and director of the University of Bristol Students’ Health Service, and GP panel member of the NICE eating disorders guidelines committee
Red flags for same-day admission
• BMI of less than 12
• Weight loss of more than 1kg per week
• Purpuric rash
• Blood pressure of less than 80/60 (postural drop of more than 20)
• Pulse rate of less than 40
• Temperature below 34.5oC
• Haemoglobin less than 90, WCC less than 2.0, neutrophils less than 1.0 and platelets less than 110
• Potassium less than 3.0
• Sodium less than 130
• Glucose less than 2.5
• LFTs that are above twice the normal upper limit
1 B-eat. The costs of eating disorders. Norfolk: B-eat; 2015
2 NICE. Eating disorders in over 8s: management. London: NICE; 2004
3 Treasure J. A guide to the medical risk assessment for eating disorders. London: South London and Maudsley NHS Foundation Trust; 2009
4 King’s College London.The SCOFF questionaire. London: KCL; 2014
• Network-ED. Available at: network-ed.org.uk
• Anorexia Bulimia Care. Available at: anorexiabulimiacare.org.uk
• B-eat. Available at: b-eat.co.uk
• Succeed Foundation. Available at: succeedfoundation.org