Obesity leaves eating disorders in the shade

Obesity is never out of the headlines at the moment; what was once a personal matter is now seen as public health enemy number one.

But does the current obsession with fat mean the NHS is ignoring the needs of those with other eating disorders - such as anorexia - and could the portrayal of the UK as a nation of fatties even be adding to the problems?

Some doctors are nervous about the increasing concentration on obesity, feeling that vulnerable young people could misinterpret some of the messages.

The weighing of children when they first join school and again in the last year of primary school is now being strengthened with parents sent letters warning if their children are overweight.

But Robin Arnold of the British Medical Association's psychiatrists committee warned of some of the consequences when this was first mooted two years ago, telling one newspaper: "It may well be justified in public health terms but one wonders what it will do to rates of eating disorders in the future."

Beat - the eating disorders association - is also aware that obesity messages could have unfortunate consequences and has been working with the government on tempering some of the messages in publicity material. Its annual report warns: "Children who are bullied about their weight and shape are particularly vulnerable."

"The campaign against obesity is a double-edged sword," says Dr Morgan, who has been working in schools on body image issues. "It could even do harm."

"Some of the messages will be detrimental to people with eating disorders," says Ms George. "All the attention paid to calorific values and what we put in our body... it's exactly the message we don't want."

And John Evans, a professor of sociology at Loughborough University, has carried out research on the impact of anti-obesity campaigns on adolescents; this showed that it could inadvertently lead to more concern about their weight and potentially propel then towards a damaging relationship with food.

Unintended consequences

The DH says its obesity strategy focuses on promoting healthy weight, achieved through positive attitudes towards a balanced diet and regular physical activity.

"We are working with experts to help ensure that there are no unintended consequences of our communications" a spokeswoman says. She adds the DH is funding research on anorexia through the National Institute for Health Research.

But one thing is clear: while obesity may be a long term risk to health, eating disorders - principally anorexia - are an immediate threat. Anorexia has the highest death rate of any psychological disorder, with 10-20 per cent of untreated anorexics dying from it. Yet it can sometimes be difficult for people to get help, even when they are willing to acknowledge the condition

This was cruelly brought home by the inquest earlier this month into the death of teenager Charlotte Robinson, whose body mass index was only 11 when she died from pneumonia.

Reluctant to have inpatient treatment, she was eventually admitted to a private clinic used by the NHS, but her condition deteriorated and she later died in an acute hospital.

The coroner who delivered a narrative verdict on her death earlier this month said there had been "inappropriate delays" which reduced the likelihood of recovery. Both Norfolk primary care trust and the mental health trust concerned have said they take the findings very seriously and, although some changes have already been made, they will look at what else needs to be done.

But are there wider problems with eating disorder services? John Morgan, secretary of the Royal College of Psychiatry eating disorders section, says provision is patchy and inadequate, and some areas pay only lip service to National Institute for Health and Clinical Excellence guidelines.

Political issue

It is hard to get figures for the number of people with eating disorders. Some put it as high as 1.1 million. Former deputy prime minister John Prescott, who recently admitted he had suffered from bulimia, had asked for statistics to be gathered on prevalence but this request was turned down by the Department of Health.

London and the South are generally better served for specialist services than elsewhere but this may hide local differences.

A review of services under way in the East of England has found substantial differences in inpatient admission rates, for example, although this is linked to what level of community provision is provided.

Beat says there is little consistency. "We are seeing more units open but not enough," says spokeswoman Mary George. "We are lobbying the government and the DH that eating disorders should be higher on the mental health agenda."

It is not easy, either, to be certain that services follow National Institute for Health and Clinical Excellence guidelines, issued in 2004. NICE itself does not monitor implementation and there is no time limit or obligation to adopt them.

Dr Morgan fears mental health services are increasingly concentrating on patients perceived as a risk to others rather than themselves alone. "There's a tendency to be dismissive about eating disorders," he says. "But it has a higher death rate than schizophrenia. Psychiatry is at risk of becoming an agent of social control."

Local practice

The first port of call for any sufferer - or sometimes their family and friends - is likely to be a GP.

In some cases GPs will deal with the problem themselves or monitor the patient for some weeks. They may refer patients to a community mental health team, where there will be varying levels of knowledge about eating disorders. Severe cases will need specialist input and possibly inpatient admission.

But Dr Morgan says: "It can take people a long time to access specialist treatment and a lot of lobbying and campaigning on their behalf. I have known cases where families have gone to their local MPs to get specialist treatment."

Norfolk PCT, which is awaiting the outcome of a review of eating disorders commissioning by NHS East of England, is now likely to commission pathways that lead to quicker specialist input.

This could reduce the need for inpatient beds: there is evidence that patients seen in a specialist service are far less likely to end up being admitted to hospital. Patients with anorexia have a median length of stay of 36 days, so services that reduce the chances of that happening could save money.

Mark Weston, assistant director of commissioning at Norfolk PCT, also expects that any changes could uncover unmet need. He would like to see increased prevention and promotion, which could create opportunities for early intervention, when outcomes are far better.

But in many places specialist services are still being developed.

The DH spokeswoman says responsibility for provision of treatment rests with PCTs but acknowledges that specialised tertiary services are available from "relatively few providers".

Kathy Chapman, locality manager with Norfolk and Waveney Mental Health foundation trust, says areas have responded to national guidance on mental health by setting up crisis intervention and other teams, but are only now focusing on more specialist services, including eating disorders.

"There has been massive transformation in mental health but eating disorders has not been the top of the list," says Ms Chapman, and many trusts are at the stage of adding more highly specialist services. "What is starting to happen now is that we are identifying a range of specialist functions which community mental health teams need to develop."

In the longer term, the trust wants to develop a specialist eating disorders service with a consultant, psychologist and psychotherapists; this could also provide support for GPs and community mental health teams working with less severe cases.

Added angst

Across the East of England, spending on eating disorders has been increasing at 30 per cent, says Jess Lievesley of the strategic health authority's public health team. The current review, prompted by access and waiting time promises in the region's response to the next stage review - is likely to lead to more consistent community services and potentially less use of inpatient beds.

In many areas, patients may have to travel more than 50 miles to access specialist services, many of which are provided by the private sector: three years ago 33 per cent of the then 29 SHAs had no specialist treatment services and only 14 per cent of patients were treated close to home. The situation may have improved since then, but provision is still patchy, says Beat. Very few units will carry out nasogastric feeding - so patients are either transferred to the acute sector or face even longer journeys.

"Young and fragile people are having to travel some distance to access treatment, which just adds to the angst they are experiencing and is a hell of a strain on the family," says Ms George. Beat's research suggests 79 per cent of families feel they suffer lasting damage from eating disorders and only 12 per cent feel they get all the support they need. The need for support and information for families was stressed in the NICE guidelines yet 82 per cent of interviewed families were not offered any literature by GPs.

Day care is proving successful, even in severe cases, says Dr Morgan, but it is difficult to provide outside big centres of population. Hub and spoke approaches where specialists work closely with community teams can help: for example a community psychiatric nurse could be trained to deliver cognitive behavioural therapy to patients with mild bulimia.

The point of release from hospital is also a concern: if services are not well developed, then clinicians may be reluctant to discharge a patient, adding to long lengths of stay. Better services in the community and a planned care pathway for discharged patients could address this.

Dr Morgan suggests that commissioning could incentivise sustainable recovery.

Many anorexia sufferers are teenagers, and may fall between services for children and for adults. Research by Beat three years ago suggested only 17 per cent of young people were treated in an appropriate setting, although this may have improved since then.

There can also be problems if they need to transfer from child and adolescent services into adult services: in some cases, there have been age gaps between the two (one finishing at 16 and the other starting at 18) and also a difference in the philosophy and approach to care.

Adult tertiary-level eating disorders will come under the new specialised commissioning groups in each SHA area from April, recognising these are low volume but high cost services which need to look beyond PCT boundaries.