Ursula Philpot

Practical Strategies for Binge Eating Disorder

GSH for BED in community weight management

Delivering Effective Recovery Focused Treatment for Binge Eating Disorder

ARFID assessment and treatment

There is increasing interest in the use of routine outcome measures (ROM’s) within healthcare and in particular Goal Based Outcomes within rehabilitation. Tees Esk and Wear Valley NHS Eating Disorders team have piloted the use of the Goal Attainment Scaling (GAS) Tool, which is a goal based outcome measure. The use of this tool specifically within CAMHS Eating Disorders teams has been evaluated trough Leeds Beckett University. The workshop will identify the need for using goals based outcome measures for both clinical staff and services users, and present themes from research in this area. It will offer examples of how to use measures in practice and explore how to overcome some of the barriers clinicians face. The workshop will promote the use of goal based outcome measures and support AHP's to start to use Outcomes Measures in practice. There will be time for discussion of case studies, how to apply the tools in specific situations and time to look at different outcome measures that are available to AHP’s

Restricted intake self-harm (RISH) is a newly described form of disordered eating presentation as a method of self-harm. The function of this behaviour is most typically to regulate emotion, communicate distress and elicit medicalised care for an unmet need. The characteristics of RISH and how it may be distinguished from anorexia nervosa (AN) are considered. A composite case series example, drawn from clinical practice, is presented, which spans a patient’s journey from their first presentation as a child and into adulthood. Optimal approaches to management, including the concept of positive risk management within a multidisciplinary framework, are described. The risks of exacerbation from using an AN treatment approach and from prolonged inpatient stays are highlighted. Awareness of this presentation is important for nutrition support teams and gastroenterologists to support early recognition, optimal signposting and liaison with appropriate services which are detailed.

Planning and delivering successful TV programmes such as these involves a considerable amount of negotiation in regard to: 1) Drama on screen, and professional boundaries/ethics and duty of care to the contributors involved. For example the producers prefer an “expert knows best” “exposing/shaming” approach which conflicts with patient centred care which is non -blaming/shaming and aims to collaboratively explore how the person become stuck in current situation and how they might move forwards . These tensions have to careful balanced to ensure a successful programme and comply with ethical and professional standards and duty of care. The onscreen impression is often misleading – what you see on screen does not reflect the package of care the contributors get. 2) Dietetic interventions that translate to screen with take home messages. For example information exchange about physiology or food science , and balanced constructive advice around diet is not exciting on screen. Therefore any educational point must have a very visual and revealing or challenging task involved. Many of the contributors are very successful during the 3 months of TV intervention work. This is due a combination of the following: • The “magical power of television” and the effect this has on hope, and positive thinking. • Access to the a very wide support team on a regular basis –including expert psychology, psychiatry, general support team, and Dietetics. • Individualised meal /exercise plans and daily contact for support to implement these • Modelling- via support teams • Innovative interventions that can happen because of resources of time, money and a team to implement. • Accountability in terms of commitment to the project on TV! There are some contributors for whom it does not seem to work as well. This is usually due to • The “magical power of television” and the expectations that brings e g “the magic wand effect” and belief that if they are “told” to stop eating, they will be able to do it. Intention gap. Inappropriate selection of contributors. The TV team select families that have considerable ( often dramatic) “back story” and will come across well on screen- due to complex back stories, intervention for behavioural goals around food and activity is often not sufficient to effect change, because fundamental psychological work has not taken place prior to behaviour change interventions. Despite expectations and commitments of contributors we do not have a magic wand and just being told to stop eating, will not work if eating is bound up with conditions such as trauma, Obsessive compulsive disorder, eating disorders etc! Some contributors will be unsuccessful on screen, and leave with new diagnosis and need for ongoing support.

This document aims to inform and support all dietitians who have contact at any level with patients with eating disorders. It provides guidance to ensure safe, effective and efficient dietetic practice. It does not cover the specifics of dietetic treatment. Disordered eating behaviours arise from psychological difficulties and are a way of coping with and communicating distress. The diagnostic criteria for eating disorders are described in the DSM IV manual (APA, 2000). A team approach is essential to the successful treatment of eating disorders and psychological therapies should be central to this team (Appendix 1). Dietitians are an important part of the team, offering timely and objective nutritional advice with the aim of helping the patient develop an improved relationship with food. Treatment may be provided within primary, secondary or tertiary services depending on the patients’ needs and local service availability. The limitations of dietetic interventions must be acknowledged due to the patients’ complex underlying psychological problems. Dietitians need to ensure they are clear about what they can offer within their professional competencies and with adequate multi-disciplinary support.

Avoidant restrictive food intake disorder (ARFID) is a classified eating disorder diagnosis with criteria outlined in both the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition and International Classification of Diseases, 11th Revision. A diagnosis of ARFID should only be made by an adequately informed multidisciplinary team. ARFID is best understood as per the Venn diagram in Figure 1. Most of the time, a person struggling with ARFID will have more than one presentation.

Eating disorders are typically and appropriately managed in specialist services. However, despite national policy recommending self-referral as an access route,1 in most cases the front door is via a referral from primary care.

Background Avoidant/restrictive food intake disorder (ARFID) is common among adults with disorders of gut–brain interaction (DGBI) presenting to gastroenterology settings. Symptoms overlap between ARFID and DGBI. How the severity of ARFID is defined can impact rates of diagnosis. Importantly, a diagnosis of ARFID can only be applied when the eating disturbance exceeds that expected from the DGBI condition. This leads to diagnostic challenges for the gastroenterology team. We aimed to explore how we could better identify “ARFID presentation” by reaching a clinically meaningful cut‐off and distinct categories for separating DGBI from ARFID and where DGBI and ARFID overlap. Methods A retrospective review of electronic health records (EHR) was conducted on 33 patients 88% female (29/33), with a median age of 44.3 ± 15.5 (range 18–73 years). All had a Rome IV diagnosed DGBI and were refractory to standard medical care, requiring both gastro‐psychology and dietitian input in a tertiary care Neurogastroenterology service during 2019. Severity criteria for meeting either strict or lenient ARFID criteria A were defined based on DSM‐5 and best practice recommendations. Results The majority (82%) met a form of ARFID criteria A. However, by applying severity levels, 33% met criteria for strict ARFID, while 49% met lenient criteria, and 18% did not meet any criteria. Discussion Adults with refractory DGBI who require both dietetic and psychological support can meet both lenient and strict ARFID severity criteria. Future research should explore if utilizing severity markers can help separate the heterogeneity of DGBI + ARFID and inform diagnostic and treatment approaches.

Coronavirus disease 2019 (COVID-19) is increasingly recognized as having significant long-term impact on physical and mental health. The Primary Care Wellbeing Service (PCWBS) in Bradford District Care NHS Foundation Trust (BDCFT) is a psychology-led specialist interdisciplinary team of health professionals specializing in persistent physical symptoms (PPS) and Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME) with an emphasis on holistic integrated care. The PCWBS quickly recognized the risk of the long-term effects of COVID-19, particularly for social, health and care staff, and developed a 7-week virtual rehabilitation course which was piloted in October 2020. The "Recovering from COVID" course takes a whole system, biopsychosocial approach to understanding COVID-19 and post-viral fatigue (PVF) and is delivered by an interdisciplinary team consisting of a clinical psychologist, physiotherapist, occupational therapist, dietitian, speech and language therapist, assistant psychologist, and a personal support navigator with support from a team administrator. The course focuses on understanding PVF, sleep optimization, nutrition, swallowing, activity management, energy conservation, stress management, breathing optimization, managing setbacks, and signposting to appropriate resources and services. Since the pilot, PCWBS has delivered 7 courses to support over 200 people suffering from post-COVID-19 syndrome. One hundred and forty-nine individuals that enrolled on the "Recovering from COVID" course completed the EQ-5D-5L to assess Health-related quality of life (HRQoL) across 5 dimensions, including problems with mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Subsequently, 76 individuals completed these measures at the end of the rehabilitation course showing that patient ratings were significantly improved. In response to the NIHR recommendation for rapid evaluation of different service models for supporting people with post-COVID-19 syndrome, this data offers hope that rehabilitation is effective in reversing some of the problems faced by people living with the long-term effects of COVID-19.

Abstract

diagnosing and managing ARFID

Under the rubric of enhancing wellbeing rather than dwelling on illness and disease, this exciting new volume not only comprises the latest evidence in the field but also advocates an approach characterised by the understanding of mental ...

The role of the dietitian in managing adult anorexia nervosa is critically discussed. The dietitian has a significant role in both community and acute settings; contributing to case management, formulation and psychological interventions. This role has evolved over time, but is now supported through a number of guidelines and literature, which are presented. Specific aspects of nutritional management including refeeding routes, feed composition, hypoglycemia and risk management are considered, with a critical look at the evidence to support practice in these areas. The development of the 2017 UK National Institute for Health and Care Excellence (NICE) guidelines, Management of Really Sick Patients with Anorexia Nervosa (MASIPAN) guidance, and post publication research are included

ABSTRACT (500-750words) Please insert in Word format for our final conference abstract book. MARSPIAN and Junior MARSIPAN guidelines are published by the Royal Collage of Psychiatry and have been developed by a multi-professional group to support clinicians making complex decision making in the refeeding of low weight patients with eating disorders. This workshop takes a closer look at the development and implementation of these guidelines, and their impact on clinical practice. It discusses the background to the development of MARSIPAN and junior MARSIPAN, starting with case examples of at recent recorded deaths through under feeding, overfeeding or a lack of joined up care management between community and hospitals teams. Strategies to prevent under or over feeding, and the complexities of managing this balance alongside dealing with staff anxiety and patient behaviours are debated. The workshop aims to support dietitians in making difficult decisions around macronutrient and energy requirements, and prophylactic supplementation of micronutrients to help prevent refeeding syndrome. These are with some evidence base, but they do not replace clinical assessment and judgement- the workshop aims to support dietitians to critically think about critical care in refeeding. Each of the clinical recommendations from the guidelines are considered, and the application of these to practice reviewed, and examples of good practice and strategies for managing patients with complex mental health needs on acute wards and discussed. Included in the workshop are reviews of some recent and post MARSIPAN publications on refeeding approaches including the use of low salt feeds, PEG feeds and supplementing diet with Nasogastric feeding. The implication of these papers and MARSIPAN guidelines on practice are reviewed.

Episodes of ravenous overeating, referred to as compulsive eating or binge eating, have been recognized clinically since the 1950s. However, the disorder of bulimia nervosa was not formally described until 1979. This article focuses on the diagnostic features of bulimia nervosa, the psychopathology and developmental course of the disorder, and the groups at risk. Specific attention is paid to the nutritional consequences of bulimia nervosa and the ways in which dietary management is used in its treatment. Finally, long-term prognosis is considered.

Eating disorders and disturbed eating behaviours are common in young people with diabetes, where manipulation of insulin or hypoglycaemic agents are often used to manage body weight. The ego-syntonic nature of eating disorders, where sufferers view the eating disorder as a solution to their problem, commonly delays diagnosis. Left untreated this dual diagnosis is a toxic mix, accelerating the incidence of retinopathy threefold (Nielsen, 2002). Diabetes teams should expect an incidence of approximately 20% in their adolescent population (Markowitz et al, 2010). Teams should be vigilant for symptoms, and the use of a validated screening tool can help with early recognition. Research into the efficacy of treatments for this population is lacking; best-practice guidance focuses on a multidisciplinary approach, with a psychological formulation of the problem that places the individual and family at the centre of treatment. Frequent whole-team contacts and enhanced communication between all professionals are essential for a successful outcome.

Anorexia nervosa has the highest mortality rate of any psychiatric condition and its management is complex and multi-faceted, requiring a multidisciplinary team approach. Dietitians are an important part of the multidisciplinary team, offering objective nutritional advice with the aim of helping the patient to develop an improved relationship with food. Refeeding patients with a low body weight requires careful management; nonetheless, refeeding the low-weight patient with anorexia presents many additional complications, largely of a psychological nature. Treatment plans need to consider psychological, physical, behavioural and psycho-social factors relating to anorexia nervosa. Currently, there is no consistent approach and a paucity of evidence to support best practice for weight restoration in this group of patients. Tube feeding is utilised at varying BMI in anorexia nervosa, mainly in an inpatient setting. However, its use should be seen as a last resort and limited to a life-saving intervention. Weight restoration is best managed by an experienced dietitian within a specialist eating disorders team, using normal foods. This approach is ideal for nutrition rehabilitation, promoting skills for eating and normal behaviour and providing a longer-term solution by challenging unhelpful coping strategies from the onset. Dietitians have a unique mix of skills and knowledge in numerous areas including nutrition, physiology, psychology, sociology and behaviour change, which can be applied to support patients with thoughts and behaviours around food, weight and appetite. Further research is required into the effectiveness of dietetic interventions in eating disorders in order to establish an evidence base for best practice.

Discussion of Dietetic/nutritional support for AN. The talk will present the latest evidence and practical approaches for : •weight gain and predicting weight outcomes in nutritional rehabilitation •refeeding rates, routes and options including MARSIPAN • dietary approaches for managing bingeing or purging • supporting patients in nutritional rehabilitation at stage of illness and managing IBS / food allergy/ sensory issues in Anorexia

An overview of food and mood with reference to how food can affect our mental health and can be used to help us improve our mood. This is an emerging area of interest internationally, but plagued by a wealth of poor quality evidence, and disparate theory. Evidence and theory are explored. The talk examines how restriction and excess can affect the brain, and focuses on evidence form cohort study linking certain food groups to better mental health.

Abstract

Eating disorders are serious psychiatric conditions which severely compromise the ability to engage in normal day-to-day living. National guidance recommends that patients are treated not by individuals but a multidisciplinary team. In the past, dietitians have been excluded from some manualised treatments for eating disorders and this has led to poor investment within some teams. However, the dietetic role goes beyond refeeding management and meal planning. This paper highlights the multiple areas where dietitians have been embedded within specialist teams and have developed advanced practice. It also explores how dietitians can bring their expertise to all areas of eating disorder treatment, including meal support, prescribing, nasogastric feeding and therapy, including, but not limited to, all variations of eating disorder cognitive behavioural therapy, family therapies for eating disorders, guided self-help and specialist supportive clinical management.

An estimated 30% of patients accessing community weight management services experience symptoms of binge eating disorder (BED). Guided self-help (GSH) is the recommended first line of treatment for BED. This study is a preliminary investigation into the effectiveness of GSH delivered by dietitians for patients with binge eating within a weight management service and a consideration of the association between wellbeing, therapeutic relationship and outcomes. The study was conducted as a single group, pre- and post-intervention study with 24 patients reporting symptoms of binge eating who completed the self-help manual with guidance from a trained community dietitian. Primary outcomes were eating disorder psychopathology and behaviours (Eating Disorder Evaluation Questionnaire), depression and anxiety. Principle results showed a significant reduction on all subscales of eating disorder psychopathology, anxiety and depression. There was a reduction in loss of control over eating but the 40% reduction in binge episodes was not statistically significant. Mid-treatment sessional ratings were positively associated with outcome. In conclusion, the GSH intervention was appropriate for dietitian delivery to patients with obesity and binge eating behaviour. This research indicates potential for other dietetic-led weight management services to deliver such interventions and support patients with binge eating accessing their service.