Eating Disorders are a Medical Emergency

Malnutrition (meaning poor nutrition) is a serious condition that happens when an individual's diet does not contain the right amount of nutrients. This blog focusses on the occurrence of undernutrition (e.g., not getting enough nutrients) as a result of over-controlled dietary intake, rather than due to long-term chronic health conditions or lack of accessibility to foods due to socio-economic factors.

This blog also uses the term underweight. This does not refer to any particular BMI. Rather, it refers to the state at which an individual is under the weight that their body functions best at. This 'ideal' weight is known as their set point range. To explain this further, here is an example of how somebody may be underweight, despite not falling into the outdated categorisation that the NHS continue to use:

• An individuals set point weight BMI is naturally 24.

• Though restrictive behaviours, the individual lowers their body weight.

• They are now a BMI of 22.

• At this 'new' weight, they are under the weight that their body wishes to be at. Therefore, they are underweight for their body.

• This individual will display psychological symptoms of malnourishment, and their bodies will suffer physical consequences.

Last Thursday afternoon, I had to explain to a family friend - a NHS licensed councillor - how it is possible that his newest client could have a serious restrictive eating disorder despite not having what is considered by the guidebooks a 'dangerously low BMI'. The Wednesday before that, I also had to explain him what gastroparesis is and why an underweight body may lower its metabolic function whilst in survival mode in to reprioritise energy expenditure.

If this has you angry, I advise you either buckle up or click off this post. This general councillor receiving referrals of eating disorder patients despite his inadequate knowledge of eating disorders does not scratch the surface of the failings going on nationwide. I want to spend a few moments giving a few more examples.

During my own 1:1 client sessions, I've had over 10 encounters with individuals who have been praised for their excessive vegetable consumption by their GP - though their volume eating has made them feel physically sick, bloated and low on energy.

I've had countless conversations with amenorrheic individuals who have been flippantly prescribed a hormonal pill, as though an absent period is nothing to be concerned about and as though focus on healing from a disordered eating and exercise habit cycle is not a more permanent solution. (Natural menses promotes long term and natural bone consolidation, mood stabilisation and fertility, in a way that a medicine does not).

In addition that, I've literally spent hours worth of session time working with clients to reassure them that they do have permission to exceed the maintenance meal plan that has been imposed upon them upon reaching their "healthy weight". If they don't, I explain, it turns into a diet plan - a rigid way of eating that is not conducive to a full life, mental freedom or provide adequate energy to the still struggling body.

As well as this, I've sat opposite a young man shed tears (of relief) upon telling him that the hunger he is experiencing after he finishes his dinner each night is not just "because he is probably thirsty", as his dietitian adamantly suggested, but rather, is more likely the phenomena of eating-induced hunger that many, many individuals who are healing from food deprivation experience.

Sadly, not all tears are good or of relief, though. There have been a couple of occasions I've been so horrified that I've so almost clambered into my car and driven to (not-so-politely) outline the definition of empathy and respect after hearing the language some clinicians are using around their patients. One particular example that comes to mind is when a doctor advised an individual presenting with symptoms of serious restriction to "come back in 3 months when their weight actually fits the BSM-5 physical criteria", rather than providing helpful resources to turn to when making a referral was out of his hands due to the binary legislations he works to.

And long before all of that, I, myself, sat through appointments of my own when I was desperately poorly, and listened to how my low heart rate was indication of my “fitness”, rather than that it was likely a warning sign that my body didn't have enough energy to pump blood around my body any faster because I wasn't feeding it enough. Or, how I could just do "a little bit of running" when my body image worsened to the point I couldn't tolerate it. Or, how the hyper-controlled breakfast that I ate each morning was comparably "much better" than another eating disorder patient who had had a session 10 minutes before me. (Guess what my ED had to say about that… “Han, you’re clearly doing Anorexia wrong…”)

I could go on and on and on. But I won't. That would make as all very sad and hopeless. That's not the purpose of this blog. I only wrote all of that out in order express a few points that I want to make sure that you are aware of if you are in recovery:

1. There are undeniable systemic failings within eating disorder treatment.

2. There are frequent occasions that harmful advice is offered at the first point of call for vulnerable individuals.

3. If individuals are offered treatment, the therapists who they are referred to may lack the specialist knowledge they require to fully support their patients.

4. Treatment is still far too weight focussed, rather than guided by an individuals mental state and symptom presentations.

5. If an individual does have an inkling of how to heal, via their reading of resources that resonate with them, they are allowed to (and should!) act on their own wisdom, truth and learning. Using the 'expert' advice as an excuse not to only serves the ED.

The current approach to treating EDs is so often inadequate and so often far too casual in nature. This lack of understanding, urgency and immediate and individualised action is meaning people are stuck with eating disorders for years, rather than months, and in a cycle of treatment, rather than 'over and out the other side'.

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"Underweight"

If somebody is under the weight that their body function best at, their body cannot function well. Thus, they are physically compromised.

If somebody is restricting, ignoring cues, and lacking nutrients due to their disordered dietary control, they are, without doubt, physically compromised.

If somebody is ignoring cues to rest and putting strain on their under-fed heart and worn out muscles by intense over-exercising, they are physically compromised.

We must stop denying this.

These people are physically compromised.

Their bodies are struggling.

Their hearts are weakening.

Irrespective of whether it looks like they are.

Irrespective of weight.

Irrespective of 'level' of restriction or intensity of over-exercise.

What we must see, is that even if an individual doesn't meet the the physical criteria of a diagnosis, displaying all of the warning signs of that illness is enough of a reason to cease questioning that individual - and perhaps instead begin to question the overly particular diagnosis.

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Being underweight is a serious medical condition.

And with that knowledge, I want to ask you a question:

Name one serious, physical, medical condition in which most people are often only referred to a talk therapist?

Yes, that's right.

There aren't any.

Except, a restrictive eating disorder.

And this is why there are so many ways in which the eating disorder treatment field must change. We need more specialised medical doctors trained in eating disorders and the physical and psychological complications of malnutrition. We need treatment providers to learn appropriate and non-invalidating terminology when conversing with at risk individuals, irrespective of a diagnosis. We need to move away from the idea that a therapist should not be the automatic first and only port of call for somebody in malnutrition. We need to be some checks in place that ensure therapists treating eating disorders need to be formally assessed for competency before they can start taking those types of referrals. And most importantly? We need to treat presentation of eating disorder symptoms as a medical emergency and as the deadly serious, physical, medical condition it is, and as an equal to other medical emergencies like cancer or heart disease.

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None of this is disregard the value of therapy...

In my opinion, all illnesses have a psychological component attached to them. In the vast majority of cases, it will be helpful to seek support with this component. But, this support should be in addition to specialist medical treatment. For some, therapy will be an integral aspect to their ultimate freedom - to heal trauma, to enable coping with weight gain, to resolve anything else underlying - but, we must also see the truth: all of this therapy will be facilitated by nutritional healing and swift emergence from the energy debt. We cannot sort out a head before sorting out the body.

If we do try that, we spend 6 months investigating the 'root cause' of the eating disorder whilst ignoring that our brains are simultaneously getting 6 months of disordered neural ingraining. We get 6 months more of the physical toll on the body becoming more acute. And finally, we get thousands upon thousands of people utterly convinced that they are psychologically damaged, rather than seeing that the effects of malnutrition are responsible for many of the issues and anxieties they are facing and this means we get thousands upon thousands of eating disorders absolutely chuffed! The eating disorders love it! It means the focus is conveniently on something other than food and weight gain! Yipee! And by the way, I know 6 months is very optimistic. It's often far longer. 6 months is often now considered a 'good' waiting list time.

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Anyway, I wrote this post for several reasons. First, because I wanted to winge. I wanted to winge because I'm tired of the traditional system failing people. I'm tired of hearing people denyed food when in treatment. I'm tired of hearing people turned away from treatment. I'm tired of hearing about waiting lists for treatment, and I'm exhausted by the treatment process itself - of therapy being the assumed course of action for all people with anorexia to take and the stories of those of us (and there are plenty) who have reached full nutritional rehabilitation without mentally healing first via therapy being ignored. Really, I'm tired that the world of medicine does not take eating disorders seriously enough.

But mainly, I wrote this for anybody who finds themselves bumbling along in their recovery, damaging their body with each day they under eat in order to maintain a body weight that is beneath where it wishes to be:

If you are underweight (by which I mean: if you are under the weight that your body functions best at), please see the urgency of this and take on responsibility for you recovery. Even if the treatment providers you have access to have not insisted immediate action is necessary, you can and must still act now. I think, deep down, you do know if you are under the weight you need to be, or do not have a relationship with food or exercise that is peaceful or conducive with a full life.

If you do have that inkling, here is my plea: for your physical health, your mental health, and all other aspects of your wellbeing, please, please act. Deep, deep, deep down, you likely know what to do. Don't wait for the permission to act on that.

You have it already from within.