Caring for patients with anorexia nervosa in the time of Covid-19

Introduction

Eating disorders are serious medical illnesses that manifest in abnormal eating habits (National Institute of Mental Health [NIMH], 2018). Those who have an eating disorder may appear healthy but are actually very ill (NIMH, 2018). People with an eating disorder can have fixed beliefs, dubbed ‘anorectic cognitions’, about the significance of weight regulation and “strong beliefs in appearance as the basis of self-worth, and inflexible views in self-control as the basis of self-esteem” (Masuda et al, 2018). These cognitions often reflect: “fear of gaining weight, perceived importance of having an ideal weight and shape as a means of being accepted by others, or perceived self-worth related to self-control over diet and weight” (Masuda et al, 2018). Several risk factors for a future eating disorder diagnosis have been identified, and include thin-ideal internalisation, body dissatisfaction, dieting and low body mass index (Stice et al, 2016).

All eating disorders have common traits, often driven by these anorectic cognitions, which are shared between the diagnosis subtypes. These traits can be broken down into emotional and/or behavioural symptoms and physical symptoms. For example, in the emotional and/or behavioural category an individual may refuse to eat certain foods or even whole food groups, for instance, no carbohydrates. In the physical category, there may be fluctuations in weight or difficulties concentrating (National Eating Disorders Association, nd)

There are several types of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, and further deviations classified as other specified feeding or eating disorders (OSFED), as well as feeding and eating disorders unspecified. This article focuses on the eating disorder subtype anorexia nervosa and the importance of recognising its signs and symptoms, particularly during the Covid-19 pandemic.

Recent research indicates that the UK’s coronavirus restrictions and lockdown became a catalyst for increased disordered eating behaviours (Brown et al, 2021). Those with an eating disorder have a complex relationship with food (Touyz et al, 2020), with the Covid-19 pandemic potentially exacerbating eating disorder-related triggers (Shah et al, 2020). For example, concerns about health and fitness during a lockdown may act as a trigger (Fernandez-Aranda et al, 2020).

Patients with anorexia nervosa may first present to health services at the emergency department (Robinson and Jones, 2018), highlighting the need for health professionals to become more aware of the diagnosis, with ‘parity of esteem’ (Box 1) being a major concern (Mitchell et al, 2017).

What is anorexia nervosa?

Anorexia nervosa is often associated with low self-esteem, negative self-image and feelings of intense distress (Mind, nd). Key characteristics include:

• Significantly low body weight for the person’s age, height and stage of development that is not caused by another health condition or food being unavailable;
• Low body weight coupled with persistent behaviour patterns to prevent a return to normal weight, which may include restrictive eating, purging behaviours or excessive exercise;
• Fear of weight gain;
• Low body weight or shape being central to the individual’s self-evaluation or wrongly perceived to be normal or even excessive (World Health Organization, 2021)

It is important to note that an individual’s symptoms may not exactly line up with the description, so that atypical anorexia or a form of OSFED may be more appropriate diagnostic terms. However, such diagnoses can be just as detrimental to the patient (Beat, ndb).

More than one fifth of respondents in an NHS Digital survey screened positive for a possible eating disorder in the age bracket 16-24 years, as did a quarter of 25-34-year-olds (NHS Digital, 2020). Around 10% of those affected with an eating disorder have anorexia nervosa (Priory, 2021). The average age of onset for anorexia nervosa is 16 years, but it can vary from 11 to 39 years (Micali et al, 2017). Although girls and women are more commonly affected, boys and men can also be diagnosed with the disease (Priory, Group, nd). The lifetime prevalence of anorexia nervosa in females is reported to be around 2-4%, with incidence rates varying from 4.2-12.6 per 100,000 for females, and 1 per 100,000 for males (National Institute for Health and Care Excellence [NICE], 2019).

Eating disorders are the leading cause of deaths among mental health conditions, with anorexia nervosa having the highest mortality rates of any psychiatric disorder in adolescents (Priory, Group, nd). Standardised mortality rates (SMRs) (Box 2) vary for those with anorexia nervosa, with research indicating rates of 1.36, 5.21 and 17.80 respectively (Himmerich et al, 2019; Steinhausen, 2002). However, there appears to be a dearth of up-to-date literature on SMRs in the UK.

Physical risks

Anorexia nervosa may cause physical health complications, ranging from minor to life-threatening, and can damage almost every body system. Loss of muscle and bone strength, and menstrual cycles stopping in women, are signs of the body failing to cope with the effects of malnourishment (Beat, ndc). Physical health risks increase as a direct result of weight loss and malnutrition, and may include the following, although this is by no means an exhaustive list:

• Miscarriage if a woman falls pregnant while acutely unwell;
• Steoporosis due to low bone density, which can increase risk of fractures;
• Heart damage;
• Nerve damage;
• Haematology problems (Schoen Clinic, nd).

Acute concerns can become chronic; for example, fracture rates increase soon after diagnosis and remain a risk for several years, even post-recovery (Westmoreland et al, 2016). Thankfully, some of these medical complications can resolve with weight gain, for example, hair thinning and acne (Westmoreland et al, 2016). However, severe anorexia nervosa can cause cardiac structure change and those with a diagnosis are at risk of sudden cardiac death which, alongside other medical complications and suicide, accounts for around 60% of deaths in the anorexia nervosa population (Giovinazzo et al, 2019; Westmoreland et al, 2016).

“The Covid-19 lockdown restrictions became a catalyst for increased disordered eating behaviours”

Mental health risks

In the interest of parity of esteem, all health professionals must also recognise the mental health risks associated with eating disorders, particularly anorexia nervosa.

Among patients with an eating disorder, figures from South Korea and Iran show more than 20% report a history of suicide attempts and the suicide risk is five-to-six times higher than in the general population (Abdi et al, 2020; Ahn et al, 2018). When assessing a person with an eating disorder, it is important to note any history of self-harm, hospitalisation history, comorbid depression and impulse regulation as these are important factors associated with suicide attempts (Ahn et al, 2018).

In the case of anorexia, around 20-40% of deaths are thought to be caused by suicide (Anorexia and Bulimia Care, 2019), a statistic that health professionals need to actively reduce. Therefore, when treating people with anorexia during necessary episodes of physical care, it is important that staff consider the whole person. For example, when weight restoration is paramount, it often requires hospital care, and in these circumstances hospital staff need to consider mental as well physical factors.

Improving management of anorexia

Management of Really Sick Patients with Anorexia Nervosa (MARISPAN), published by the Royal Colleges of Psychiatrists, Physicians and Pathologists (2014), was in response to concerns that people with anorexia nervosa were deteriorating and dying at a disproportionate rate, due to psychiatric and medical complications, after being admitted to general medical units. The guidance makes several recommendations, including how to manage people with anorexia nervosa in different settings. It has been recommended by NICE for inpatient and day patient treatment, and for managing refeeding syndrome (NICE, 2017).

Early intervention for an eating disorder may help prevent illness onset or lead to an improved course of illness (Royal College of Psychiatrists, 2019). Box 3 suggests an approach all health professionals could adopt when a presentation of anorexia nervosa occurs in clinical practice.

Effect of Covid-19

There are concerns that the negative psychological effects of Covid-19, and successive lockdowns, could reduce people’s motivation and the ability to recover from anorexia nervosa (Walsh and McNicholas, 2020). Factors may include practical difficulties around food, such as physically accessing food, medical appointments being cancelled or no longer held face-to-face, and changing routines that are unsettling for people with eating disorders (Beat, nda).

In addition, Covid-19 has been identified as the catalyst for an increase in disordered eating behaviours, with social restrictions (such as isolation and increased responsibility for self), functional restrictions (such as lack of routine and structure and a need to plan activity), and restrictions to mental health services, negatively affecting people with eating disorders (Brown et al, 2021). In an online survey, more than 40% of people with anorexia nervosa “agreed”, or “strongly agreed”, that Covid-19 had worsened their eating disorder, and more than 50% “agreed”, or “strongly agreed” that it had worsened their quality of life (Schlegl et al, 2020), highlighting the negative effect on people with anorexia nervosa.

Summary

It is important to recognise the concerns that a diagnosis of anorexia nervosa can present in the clinical environment. The risks to patients can be high, from both a medical and psychological perspective, and can also be difficult to manage. Although easing of lockdown restrictions can be viewed as a positive, we need to consider if another change in routine will have a further negative impact on this patient group and be prepared as health professionals to manage this.