Authors: Liz Herrieven / Editor: Charlotte Davies / Codes: CAP30, MHC3, SaC3, SLO1, SLO5 / Published: 13/06/2023
Eating disorders are an area most emergency physicians probably feel they know a bit about, but have been happy to leave to specialists to manage. Specialist management is absolutely needed, but with Emergency Department (ED) attendances with these conditions hitting higher numbers than ever, and a huge burden of mental and physical health needs carried by patients with eating disorders, ED clinicians need to be aware of how they can give the care needed. New guidelines were published in May 2022, to help us do just that. Medical Emergencies in Eating Disorders1 replaces the previous guidance (MARSIPAN and Junior MARSIPAN).
Before we go any further, just to keep things clear, although “Eating Disorders” are often abbreviated to “ED”, for the purposes of this blog we’ll stick to long-hand and the full title. ED will be used as the abbreviation for Emergency Department.
What are eating disorders and why do I need to know?
So, eating disorders… These are a group of conditions including anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID (avoidant restrictive food intake disorder) and the usefully-titled OSFED (other specific feeding and eating disorders) and UFED (unspecified feeding and eating disorders). All involve abnormal and disturbed beliefs about eating with resultant psychological and physical health issues which are closely intertwined. They can affect any age and any gender. A person may have one type of eating disorder or may have more than one, or may move between types. Eating disorders are illnesses, not a lifestyle choice. Recovery is possible, but needs specific management and support.
ED attendances by patients with eating disorders increased dramatically in recent years (84% greater attendances at EDs according to RCPsych over the last 5 years), particularly over the pandemic, likely related to the impact of social isolation and information linking weight with COVID-19 risk. Not only were there increased rates of new cases, but an increased likelihood of relapse for those who had been recovering from an eating disorder. Patients have been presenting at younger ages and with more severe or advanced illness. Eating disorders have the highest mortality rate of any psychiatric illness, with approximately 1 in 5 deaths due to suicide and 4 in 5 due to physical causes of death such as hypoglycaemia or arrhythmia. Eating disorders are also closely linked with other mental health problems, self-harm, overdose and suicidal ideation. Patients with an eating disorder are 1.6 times more likely to attend the ED than those without.
Anorexia Nervosa is probably the eating disorder we hear about most often. It involves a persistent energy intake restriction relative to requirements leading to a significantly low body weight, with an intense fear of gaining weight or becoming fat and persistent behaviours that interfere with weight gain. Those behaviours might include restricting food and fluid, excessive exercise, vomiting, disappearing after meals, laxative use and food-sabotaging behaviours such as spitting, excessive chewing or disposing of food.
Bulimia Nervosa involves recurrent episodes of binge eating – eating, within a discrete period of time, an amount of food which is larger than it would be usual to eat. There may be a sense of lack of control and recurrent inappropriate compensatory behaviours such as vomiting or excessive exercise.
Avoidant Restrictive Food Intake Disorder
ARFID is a relatively newly described form of eating disorder and involves intense restriction of food intake but with an emphasis on the type of food rather than on weight gain or loss. There may be sensory aversions (such as those involved in sensory processing disorders and autism spectrum conditions) or fears around choking or vomiting. The resultant limitations on food intake can lead to similar physical issues as those encountered in anorexia or bulimia with weight loss, muscle loss, skin and hair problems, reduced levels of nutrients and vitamins, hypoglycaemia, reduced metabolic rate and arrhythmia, for example.
Physical Problems in Eating Disorders
Patients with eating disorders are at risk of a wide range of physical health problems, even with a normal BMI. Presentations might be difficult to unpick, with atypical symptoms and incomplete histories. Acute malnutrition is a medical emergency and, again, can happen with a normal BMI. Hypoglycaemia may be chronic and so, with adaptive ketosis, patients may not be as “flat” as you’d expect with a very low blood sugar. In those who are diabetic, skipping insulin is common (as insulin is well-known to cause weight gain) so diabetic patients who have an eating disorder may present in DKA2. Refeeding can be as dangerous as starvation3, with an endogenous insulin surge causing huge electrolyte shifts.
Patients (or their families) might declare a history of eating disorder and may have presented because of concerns around acute weight loss. More commonly, the eating disorder may be hidden, or there may not have been a formal diagnosis. Your patient might be wearing extra layers of clothes and may not want to get undressed for examination, or might be evasive with questions and appear secretive. The SCOFF questionnaire4 can be helpful, particularly in identifying Anorexia Nervosa or Bulimia Nervosa, with two or more positive questions raising your index of suspicion (100% sensitivity, 90% specificity).
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone in a 3 month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
Behaviours and Mental Health
Apart from the increased risk of self-harm and suicidal ideation, patients with eating disorders may present with a number of other mental health problems. They may be frightened or miserable. They may be agitated or restless. Visual attention may be reduced, along with non-visual memory, and executive function may be altered with subtle but serious issues with the ability to make decisions. Patients with an eating disorder may appear to be argumentative or manipulative, but it is important to remember that this is a symptom of the eating disorder. Eating disorders can have a huge amount of control over a person and make them behave in ways they would not normally do. Try to see the person, not the disease.
ED Assessment and Management
So what do we need to do in the ED? First off – consider eating disorders in the first place. Better awareness amongst clinicians means we are more likely to notice patients who are affected. Next, we have to be compassionate and considerate. Watch what you say and how you say it. Don’t comment on weight or appearance (even if you are well-meaning). Give patients the option to be blind-weighed (so they don’t see the weight), with weights noted discretely in the notes. Weights can be falsified (for example, by drinking a large volume of water) so consider measurement of mid-upper arm circumference or the SUSS test5. Weight and BMI can be in the normal range, but the patient still be critically ill, either from starvation or refeeding syndrome. Remember, the disease is in control, so try to see beyond any manipulative behaviour to the patient themselves. Don’t be judgemental. Eating disorders are an illness, not a lifestyle choice, and a frequently fatal one at that.
Consider using the SCOFF screening questions and carry out a systematic physical assessment. Monitor heart rate, ECG, BP (including orthostatic changes) and check a full blood count, renal function, liver function and bone profile (but remember, bloods can be normal, but the patient may still be seriously unwell).
The MEED6 guidance includes summary sheets for a wide range of professionals, including a guide for ED staff7 – this is incredibly useful and definitely worth referring to during your assessment.
Patients deemed to be at high risk should be admitted under the care of acute medical (or paediatric) teams for stabilisation and safe refeeding. They should also be referred for a psychiatric assessment and, ideally, a specialist eating disorder bed (although these are in high demand and low number). If well enough to go home, ensure a referral to the local eating disorder service has been made. For patients in the ED, unless under a section 1368, there is a high risk of leaving the ED against medical advice. Follow the Mental Capacity Act9 but remember that eating disorders can cause subtle changes in capacity and the disease may cause patients to become adept at deceit and manipulation.
This can all be very daunting – not just for the patients, but also for clinical staff unfamiliar with caring for patients with eating disorders. The MEED guidance can also appear pretty daunting – the main document is 185 pages long – but the ED guidance (section 13 of Annexe 17) is only 3 pages and is concise and very helpful.
So have a high index of suspicion, remember the risks and pitfalls, stay non-judgemental and follow the guidance. That way, we can give our patients with eating disorders the care and support they deserve.
- Royal College of Psychiatrists, Medical Emergencies in Eating Disorders: Guidance on Recognition and Management (Replacing MARSIPAN and Junior MARSIPAN). COLLEGE REPORT CR233. May 2022. Updated March 2023.
- Royal College of Psychiatrists, Guidance on Recognising and Managing Medical Emergencies in Eating Disorders (Replacing MARSIPAN and Junior MARSIPAN). Annexe 3: Type 1 diabetes and eating disorders (T1DE). May 2022.
- Nickson C. Refeeding Syndrome. Life in the Fast Lane, 2020.
- Morgan J F, Reid F, Lacey J H. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999; 319 :1467.
- Royal College of Emergency Medicine, Royal College of Psychiatrists. Safety Flash. Anorexia Nervosa. January 2020.
- Royal College of Psychiatrists, Medical emergencies in eating disorders (MEED) Guidance on recognition and management. CR233, May 2022.
- Royal College of Psychiatrists, Guidance on Recognising and Managing Medical Emergencies in Eating Disorders (Replacing MARSIPAN and Junior MARSIPAN). Annexe 1: Summary sheets for assessing and managing patients with severe eating disorders. May 2022.
- Dick T. Mental Health in the ED – Induction. RCEMLearning, 2020.
- Herrieven E. The 3Cs of Paediatrics. RCEMLearning, 2019.
- Image 1 – Russell’s Sign. Kyukyusha, Public domain, via Wikimedia Commons.