COMMUNITY
EATING DISORDERS: ENCOURAGING UNDERSTANDING AND COMPASSION Nikki Brierley Specialist Dietitian and CBT Therapist
Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist. She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust. REFERENCES Please visit the Subscriber zone at NHDmag.com
Eating disorders are complex mental health conditions that effect over 1.25 million people in the UK.1 They are often misunderstood, subject to stigmatisation and conversely sometimes praised/ promoted within the current diet culture. Increasing awareness, understanding and compassion in this area may be vital to help ensure improved access to treatment and to enhance overall outcomes. Eating disorders (ED) are defined by negative beliefs and behaviours concerning eating, body shape and weight and can result in restricted and/or binge eating and compensatory behaviours. The emotional and physical consequence of these beliefs and behaviours maintain the disorder and can make recovery difficult to achieve without appropriate support.1 ED can have devastating effects on those struggling with the conditions and can also greatly affect those around them. They are associated with poor quality of life, social isolation and can have a substantial negative impact on family and carers.1 Research suggests that early identification and treatment is associated with improved outcomes. It appears, however, that from the onset of symptoms, an average of three and a half years pass before specialist treatment is accessed. This is thought to be partly due to symptoms not being recognised, followed by a delay in patients asking for help once symptoms are apparent, then a further delay before services are made available.2
Identifying symptoms and assessing for ED can be extremely challenging. Commonly, individuals experiencing these disorders find it difficult and/ or distressing to discuss ED cognitions and behaviours.1 Possible reasons for this include the level of shame that can be experienced and the stigma attached to the potential diagnosis. As such, raising awareness of ED is needed to improve understanding and promote treatment. An event that aims to get more people talking about ED, reduce the stigma and misunderstanding and help individuals know they are not alone is Eating Disorders Awareness Week�. This is an annual event promoted by BEAT, a UK ED charity, and has previously focused on different areas of interest (i.e. self-esteem and ED in the workplace). In addition to national campaigns, it is vital that dietitians and other healthcare professions are aware of and promote awareness of the early signs and symptoms of ED.
Table 1. Spotting the first signs of an eating disorder Word/prompt
Question to consider
Lips
Are they obsessed with food?
Flips
Is their behaviour changing?
Hips
Do they have distorted beliefs about their size?
Kips
Are they often tired or struggling to concentrate?
Nips
Do they disappear to the toilet after meals?
Skips
Have they started exercising excessively?
Adapted from: www.beateatingdisorders.org.uk/uploads/documents/2017/9/tips-poster.pdf
www.NHDmag.com April 2018 - Issue 133
41
COMMUNITY Table 2. Factors to consider when assessing for an eating disorder An unusually low or high BMI or weight for age. Rapid weight loss. Dieting or restrictive eating practices that are worrying them or others. Family or carers reporting a change in behaviour. Social withdrawal, particularly from situations that involve food. Other mental health problems. A disproportionate concern about weight or shape. Problems managing a chronic illness that affects diet (i.e. diabetes or coeliac disease). Menstrual or other endocrine disturbances or unexplained GI symptoms. Physical signs of malnutrition (i.e. poor circulation, dizziness, palpitations, fainting or pallor), or compensatory behaviours (laxatives, diet pills, vomiting or excessive exercise). Abdominal pain associated with vomiting or restrictive diet that is not explained by a medical condition. Unexplained electrolyte imbalances or hypoglycaemia. Atypical dental wear. High risk activities associated with increased risk of eating disorder (i.e. professional sports, fashion, dance or modelling). Adapted from: NICE (2017), Eating Disorder: Recognition and Treatment, Guideline 69
When assessing for a possible ED, there are a variety of factors to consider: Table 1 provides a simple list of easy-to-remember prompts that can be used to spot some of the first signs. This may be useful to encourage individuals to review their behaviour and/or assist family members, friends and colleagues to encourage further assessment/support. Table 2 provides a list of factors to consider when assessing for an ED and considering a referral to a specialist ED service. ENCOURAGING COMPASSION
Compassion can be defined as, ‘sympathetic pity and concern for the sufferings or misfortunes of others’,3 or a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering‘.4 This can sadly be missing by those interacting with individuals with an ED, which can further increase the feelings of shame and self-judgement and reduce feelings of selfcompassion. Self-compassion can be described as the ability to extend compassion to oneself and is thought to comprise of self-kindness, common humanity and mindfulness. Research suggests that low self-compassion is associated with an 42
www.NHDmag.com April 2018 - Issue 133
increased risk of negative mental health and that increasing self-compassion can have a positive effect on mental health and wellbeing.5 There are a variety of exercises that can encourage the development of self-compassion, two of which are summarised in Table 3. Additional information and activities to increase self-compassion are available at www.self-compassion.org. Demonstrating, modelling and encouraging compassion and self-compassion can, therefore, be imperative when raising awareness, developing a therapeutic relationship and promoting recovery. In order to achieve this, it is important to notice and acknowledge the suffering that is taking place; it is essential to recognise that behind the symptoms and a diagnosis is an individual who is struggling to cope and who has found some sort of comfort, safety and consistency from an ED. It is important to remember that the common myths about an ED are incorrect: it is not “a lifestyle choice”; it is not “extreme vanity”, neither is it just “attention seeking behaviour”, nor a phase that the individual will “grow out of”. Instead, it is essential to keep in mind that an ED is an expression of an anxiety disorder, a maladaptive coping strategy that can develop due to many different factors. In essence,
Table 3. Encouraging self-compassion Exercise
Explanation
How would you treat a friend?
Consider how you would respond to a close friend who was struggling or suffering in some way. Compare the language used to how you might talk to yourself in a similar situation. Explore why there are differences. Try talking to yourself as you would a close friend and notice the differences in how you feel and behave.
Self-compassion break
Evoke the 3 aspects of self-compassion. Consider a situation that causes stress. 1 Acknowledge the suffering (mindfulness). 2 Accept suffering is part of life (humanity). 3 Express a kind statement to self (self-kindness).
Adapted from: www.self-compassion.org/category/exercises
an ED communicates pain and if that pain and suffering is met with harsh judgements (which are often taking place internally for the individual experiencing the difficulty), then recovery can be problematic. However, if the pain is acknowledged, met with compassion, kindness, warmth and understanding, then the journey towards recovery can be improved. DISCUSSION
As dietitians and healthcare professionals, it is important that we consider our role in promoting understanding and compassion within ED. It appears highly relevant that despite our specialism or area of work, we ensure that our understanding and knowledge stays up to date about the signs and symptoms of ED. Also, that we know how best to raise and discuss any concerns with individuals, family members, or carers and that referrals to specialist services are completed when appropriate. It also seems important that we consider our own level of compassion towards ED and, indeed, our own self-compassion. It is essential that we consider how the health, eating and weight messages that are regularly promoted can contribute to increased risk of developing ED. We need to consider our interactions with individuals, groups or wider populations and how these can potentially impact on those who are struggling with, or at risk of developing, ED cognitions or behaviours.
If directly working within ED treatment, it is extremely important to reflect on our direct interactions and the importance of compassion. It is also vital to always remember that the disordered eating behaviours are only symptoms of the mental health condition and, therefore, recovery is not achieved by making changes to these behaviours alone. Indeed, focusing on such changes as diet and weight can have a further negative effect and greatly increase suffering and risk. SUMMARY
ED are multifaceted mental health conditions that are commonly misunderstood and stigmatised. An increase in general awareness and understanding is needed, as well as help to encourage prompt access to effective treatment. Compassion can sadly be missing and considering methods to increase this (including self-compassion) may prove to be very beneficial. As dietitians and healthcare professionals, it is important that we consider our interactions and the potential effect of the health messages that are regularly promoted. We need to recognise that those suffering with, or at risk of developing, an ED can be negatively impacted by the promoted ideals of health, weight and diet. It is also imperative that efforts are continued to be made to increase awareness, understanding and compassion in this complex area. www.NHDmag.com April 2018 - Issue 133
43