Eating Disorders: The implications of starvation and importance of nutritional rehabilitation

Dr Anthea Fursland (Associate Director and Consultant Clinical Psychologist) and Dr Lisa Miller, (Psychiatrist and Medical Director) at the WA Eating Disorders Outreach & Consultation Service

Increasingly, eating disorders are understood as neurobiological disorders, sitting at the interface of physical and mental health.  Emerging evidence suggests early intervention, including assertive nutritional rehabilitation and structured psychological support with a multidisciplinary plan for relapse prevention, can significantly improve prognosis.

Severe malnutrition and ‘starvation syndrome’ (1) can be experienced in people at any weight, resulting in physical and cognitive effects including poor insight regarding nutritional and medical risk. Severely malnourished individuals are unlikely to be able to reverse starvation on their own.

Sometimes people with high risk medical complications or recurrent presentations may require inpatient admission to enable nutritional rehabilitation/weight gain to a level sufficient for brain recovery from malnutrition. Otherwise, this will continue to drive cognitions and impair engagement with psychological treatments, perpetuating the cycle of weight loss and readmission. Access in Perth to public psychological services and private day programs for people with eating disorders requires a BMI >16 kg/m2, and BMI  ≥17kg/m2 is associated with improved ability to benefit from outpatient treatment (2).

Prevalence, screening and early intervention
Eating disorders are not rare. A longitudinal study from WA showed that by the age of 17, 15.2% of females have a diagnosable eating disorder (3). Since shame often hinders people from seeking help and early intervention is known to improve prognosis, all patients should be asked about their eating habits and whether they purge, binge and/or severely restrict their food. A screening tool such as the SCOFF can help identify disordered behaviours and cognitions. Trustworthy psychoeducation, such as handouts provided by the Centre for Clinical Interventions,  is helpful in explaining such concepts as the need for regular eating, the dangers of purging and the effects of starvation.

Medicare changes and evidence-based treatments
From 1 November 2019, Medicare reimbursement will be increased for people with severe eating disorders. Dietitians will be able to provide up to 20 sessions per year and psychologists up to 40 sessions. (To obtain beyond 20 mental health sessions, the individual will need to be assessed by a psychiatrist or paediatrician).

Whilst assertively addressing nutritional rehabilitation goals with people experiencing eating disorders can be challenging, it is also critical to recovery i.e. just talking to someone about their eating disorder, without changing the behaviour is unlikely to be helpful. Therefore it is important that GPs refer their patients to psychologists and dietitians who offer evidence-based treatment, which involves:

  • A focus on the current eating disorder
  • Early change
  • Reducing eating disorder behaviours (restriction, binge eating, purging, driven exercise)
  • Weekly weighing
  • Weight regain for those needing it
  • A focus on eating regularly and reducing food avoidance by exposure to food and eating.

The local Women’s Health and Family Services Eating Disorders Resources Directory, which lists practitioners with expertise in this area, can be accessed via the ‘Eating Disorders Specialised Assessment’ HealthPathway.

The two most widely used evidence-based psychological treatments are:

  • Family Based Treatment (FBT) – for adolescents with anorexia nervosa
  • Cognitive Behaviour Therapy (CBT) – for all diagnoses and all ages from adolescence.

Although the onset of anorexia nervosa and bulimia nervosa is usually in the teen years, binge eating disorder can develop at any age, and affects men in equal numbers. Patients presenting in later life may have tried many treatments, but the evidence suggests that evidence-based approaches can still work with this older group and that even longstanding eating disorders can be treated successfully (4,5).

Eating disorders are complex in nature, cause enormous distress to patients and their families, and carry a large burden of care. Because of this, it is critical to screen for eating disorders, intervene early and refer appropriately, plus provide regular medical monitoring. The WA Eating Disorders Outreach & Consultation Service (WAEDOCS) is available to support clinicians throughout the state and can be reached on 1300 620 208. WAEDOCS has also created clinical guidelines  to facilitate best practice care.

More information can also be found in the recently completed the “Eating Disorders” HealthPathways.

 

References:

  • Keys, A. The Biology of Human Starvation. Minneapolis, MN: University of Minnesota Press; 1950.
  • Wade, T., Allen, A., Crosby,R., Fairburn, C., Fursland, A., Hay, P., McIntosh, V., Touyz, S., Schmidt, U., Treasure, J. & Byrne, S. (2017) Trajectory of weight change over the first 13 sessions of outpatient therapy for anorexia nervosa and relationship to outcome, International Conference on Eating Disorders, Prague
  • Allen, KL, Oddy, WH, Byrne, SM & Crosby, RD (2013) DS M-IV-TR and DSM-5 Eating Disorders in Adolescents: Prevalence, Stability, and Psychosocial Correlates in a Population-based Sample of Male and Female Adolescents. Journal Abnormal Psychology. 122 (3) 720-732
  • Raykos, B., Erceg-Hurn, D., McEvoy, P., Fursland, A. & Waller, G. (2018) Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from enhanced cognitive behaviour therapy. Journal Consulting & Clinical Psychology. 86, 8; 702-709
  • Eddy, KT, Tabri, N, Thomas, JT, Murray, HB..& Franko (2016) Recovery from Anorexia Nervosa and Bulimia Nervosa at 22-year follow-up. J Clinical Psychiatry

 

 

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